Referral Form - Junaya

Geographical Details:

Junaya Family Development Services provides a range of programs for families and their children. Parenting Programs are available for parents and family members from any location. Individual support is available for people living in the Blacktown LGA

Do you live in the Blacktown LGA?
If not

which area do you live in?

Purpose of referral

What is the main reason for this referral to Junaya Family Development Services? Provide a brief description:

What do you hope Junaya will provide or achieve in supporting the family?

JFDS has Weekly Allocation Meetings on Friday morning. Is this referral needing a response within 48 hours?

Section 1 – Information about the person being referred

Date of referral:

Preferred Title:

Mr
Mrs
Ms
Miss
Mx

Preferred Name/s:

Family Name

Given Names:

Gender

Male
Female
Non-Binary
Prefer to self-describe

Date of Birth:

Contact phone number:

Email:

Address

Address Line 1

City

State / Province / Region

Emergency contact Name:

Emergency contact phone:

What language/s do you speak?

What country were you born in?

Do you need an interprete

Junaya Family Development Services does not provide interpreter services for parenting programs. If you need interpreter services, we can connect you with services that can support your language needs

Do you identify as Aboriginal?

Do you identify as Torres Strait Islander?

Do you identify as having a disability or a medical diagnosis? If yes, please state:

Information to support JFDS meet any specific or diverse needs you might have?

I have some support needs with reading and writing

I have some support needs with reading and writing

Current living arrangements:

Living with Family
Homeless
Live in Refuge
Sole Parent with Child(ren)
Couple with Child(ren)
Couple without Children
Other Family

Select Number of Child

Child 1

Child 1: Name

Child 1: DOB

Is the child

Male
Female
Non-binary
Other

Child 1: Name of Childcare / Preschool / School

Child 1: Current care arrangements

With parent/s?
Alternate care with / without DCJ Restoration plan

Child 2

Child 2: Name

Child 2: DOB

Is the child

Male
Female
Non-binary
Other

Child 2: Name of Childcare / Preschool / School

Current care arrangements

With parent/s?
Alternate care with / without DCJ Restoration plan

Child 3

Name

DOB (copy) (copy)

Is the child

Male
Female
Non-binary
Other

Name of Childcare / Preschool / School

Current care arrangements

With parent/s?
Alternate care with / without DCJ Restoration plan

Child 4

Name

DOB

Is the child

Male
Female
Non-binary
Other

Name of Childcare / Preschool / School

Current care arrangements

With parent/s?
Alternate care with / without DCJ Restoration plan

Child 5

Name

DOB

Is the child

Male
Female
Non-binary
Other

Name of Childcare / Preschool / School

Current care arrangements

With parent/s?
Alternate care with / without DCJ Restoration plan

is the parent pregnant

Is the parent pregnant

Are there any current concerns about safety or wellbeing of you or your children? This can include concerns about mental health, violence or abuse, or thoughts about suicide / self-harm. If urgent, notify management immediately.

No
Yes (if yes, details about safety concerns, including information about current AVOs)
Would you like to discuss these safety concerns further before meeting with a worker or attending a parenting program?

Junaya Family Development Services can provide individual support through Family Capacity Building and other specialist support for parents who have the care of their children as well as parents who have a formal plan for restoration with DCJ.

Note: If a parent is seeking restoration and does not have either care of their children or a formal plan for restoration with DCJ, they are welcome to engage with any one of the Parenting Programs offered by Junaya. See details in Section 5.

Are the children currently in the care of the parent requesting the service?

Is DCJ currently working with the family?

Is DCJ currently working with the family?

Are the children currently living in alternate care arrangements?

Are the children currently living in alternate care arrangements?

If yes, is there a formal plan for Restoration with DCJ?

Name of DCJ caseworker?

CSC: (office)

Do you give verbal consent for JFDS to contact the DCJ caseworker to get information about the restoration plan?

Junaya Family Development Services provides support for families experiencing a range of issues. Which of the following issues are you currently experiencing?

Financial
Housing
Parenting
Alcohol and/or other drugs
Mental health
Legal
Domestic or family violence
Family relationships
Isolation
Health and wellbeing

Issues currently experiencing

Are there currently any Family Law proceedings

Are there currently any Family Law proceedings

Are you receiving supports from any other agencies?

his information helps us to work with other agencies where you give your consent and enables us to provide the best support for you.

Please name any agencies you are currently receiving services from:

Service Type requested

Junaya family Development Services provides different programs.

Family Capacity Building– 12 weeks support with a family worker to identify needs and set goals for change. This is for families who have care of their children or a formal restoration plan with DCJ. It includes working with the family to set goals to create change where there are issues impacting on parenting which may also affect children’s safety and wellbeing
Parenting Program – group programs to support parents improve their parenting skills. There are a number of Parenting programs, and these are available to all parents who want to build skills in their relationship with children or understanding and responding to children’s behaviour and development.

Parenting Programs where a parent is seeking restoration

Is attendance at parenting group:

Ordered by the court?
Part of a formal plan for restoration?
Parents want to build capacity to apply for restoration in the future

What is the main reason for this referral to JFDS parenting programs?

What are you wanting to learn or develop from the program?

Which parenting programs are you interested in? (to be referred to PSO for further assessment)

Bringing up Great Kids
Circle of Security
Tuning into Teens

Have you attended any of these programs before?

Childcare

Do you require childcare when attending the parenting program:

Transport

Groups will be held at Junaya Family Development Services in Blacktown. Will you need support arranging transport?

Current support services (knowing which services you are in contact with helps us to provide the best support to meet your needs)

Do you currently receive other support services from Junaya Family Development Services?
Are you currently receiving support from another service?
Do you have a caseworker or support worker?

Details

How did you find out about Junaya Family Development Services Programs

Website
DCJ
Other Services
Social media
Other

The information you provide on this form includes your personal information. Your personal information is protected by law, including the Commonwealth Privacy Act.

We are using an IT System called the ‘Data Exchange’ to store your information. This system is hosted by the Australian Government Department of Social Services (DSS). The personal information that is stored on the Data Exchange is only disclosed to us for the purpose of managing your case.

You do not have to consent to sharing your personal information with DSS. If you do not consent to us sharing your personal information, it will not affect the services you receive. If you do not consent to sharing your personal information with DSS, you can ask for this information to be removed at any time.

DSS de-identifies your data. This means they remove information that identifies you or that could be used to re-identify you (e.g., your name).

DSS combines your data with other clients’ data in the Data Exchange to identify trends at the program level. This information is used to develop policy, administer grant programs, and conduct research and evaluation. DSS may use this data to produce reports which may be shared with other organisations.

The data in these reports is de-identified.
You can find more information about how DSS will manage your personal information in the DSS privacy policy on their website https://www.dss.gov.au/privacy-policy
This policy explains:

how to access the personal information that is stores about you on the Data Exchange
how you can ask for this information to be changed or removed
the circumstances in which DSS may disclose personal information to overseas recipients
how to complain about a breach of the Australian Privacy Principles by DSS, and how DSS will deal with your complaint.

I consent for my personal information to be stored in the Data Exchange

I consent to participate in follow up Research, Surveys or Evaluation