POST SEPARATION SERVICES
Application Form
Please select the required location and service.
SERVICE
CHILDREN’S CONTACT SERVICE
□
□
Facilitated Change Over
□
Supervised Visit
Post Separation Co-operative Parenting Program (Seminar)
* Co-operative Parenting Program (PSCOP) is compulsory for all clients accessing CCS.
APPLICANT DETAILS
First name:
Surname:
Any other names known by (eg maiden name):
D.O.B:
Postal Address:
Postcode:
Phone: (h)
(M)
Email:
Are you the parent the child lives with
Parent the child spends time with
Relationship to the child/ren:
Mother
Father
Other
If other, please specify:
Are you Aboriginal/Torres Strait Islander Yes
No
What is your country of birth
What is the main language spoken at home
Do you require an interpreter?
Yes
No
If yes, which language?
DETAILS OF CHILDREN TO BE INVOLVED IN REQUESTED SERVICE
Name:
Name:
Name:
Name:
D.O.B
D.O.B
D.O.B
D.O.B
M
M
M
M
F
F
F
F
Language spoken (if other than English):
What suburb/town do the child/ren reside:
AN APPLICATION FORM IS TO BE FILLED OUT BY EACH PARENT*
Application forms need to be received from both parents before we can consider your request
If you require assistance with paper work please contact the service.
*The term ‘parent’ is interchangeable with significant person in the child’s life requiring this service.
All applications that do not proceed will be disposed of after a twelve month period.
POST SEPARTION SERVICES APPLICATION FORM, March 2017
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