Family Group Conferencing - Referral Form

Instructions for Caseworkers

1. Please complete the referral document once permission from the key family members have been
obtained, including all relevant family details.
2. Consent is required from parents/carers to send personal information to Many Hands Consultants
before the document will be reviewed
3. Once received Many Hands will determine if an FGC is suitable for the family.
4. If a parent/carer provides verbal consent with the ability and willingness to provide written consent
later the referral will be accepted

REFERRAL DETAILS:

Referral date:

Referrer Name and contact details

FAMILY DETAILS

Does the family identify as Aboriginal or Torres Strait Islander? Yes/NO

What are the cultural needs of the family to be considered?

Parent Carer 1:

Address:

Phone Number:

Parent Carer 2:

Address:

Phone Number:

Parent Carer 3:

Address:

Phone Number:

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 Children/young people information

Name
Address D.O.B Sex Living with? Are there any
Current orders?

Significant other details: (please list any other family members or anyone that is significant to the family that
you have any information for)

Name
Address D.O.B Sex Relationship to the child?
Any Comments

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 Family Details Continued….

Does anyone in the family have a disability? If so please list and comment on any consideration in preparation
and FGC meeting Facilitator needs to consider when planning for the family’s FGC.

OTHER AGENCIES INVOLVED:

AGENCY and Worker CONTACT PHONE Involvement

Additional Information Required:

1- Please Attach a Family Genogram

2- Any reports or court orders essential for the facilitator to prepare for a Family Group Conference.

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CONSENT INFORMATION

FGC is a voluntary process and the parents/carers need to consent to participation and to the release of their
information to Many Hands.

Is the family aware of the referral? Yes or No

Does the family(at least one significant carer) consent to the referral and release of information? Yes or NO?

Does the family give verbal or written consent? YES or NO? Verbal or Written?

Has the family been given information on what a FGC is? Yes or NO?

Is the family willing to discuss an FGC further with Many Hands? Yes or No?

Referrer Declaration:

I, ………………………..…… caseworker of ……………….

Date

Confirm the details in consent information is true and I have obtained verbal or written consent voluntarily by
the family being referred.

Signed worker...............................................................

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Consent or parent/carers or young people over 16 years

I/We, .................................................................................. .......................

……………………………………………………………………………………
(please print your name/s)
I have been informed of a referral being made to Many Hands for a Family Group Conference.
I am aware that this referral is voluntary and I have chosen to participate

Consent for Provision of Information for Referral to Family Group Conferencing

I/we further consent on behalf of the following child/ren under 16.

I/We have been informed about how our personal information will be used and we give my/our
information voluntarily
Signed by Carer / Parent(s) Date

Signed by Carer / Parent(s) Date

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