{14 Client Name}
Ay
Date:
Date Placement required:
DHS Client No:
CSO Client No:
Approval for Placement
Decision to refer for placement approved by:
Name:
Position:
Worker
Name
Office
Direct Phone No
Mobile Phone No
Email
Team Leader
Name
Office
Direct Phone No
Mobile Phone No
Email
DHS PLACEMENT REFERRAL FORM
For a child or young person to be looked after by a placement agency
1.0 Child/Young Person
Name
Also known as
Date of Birth/
Age
Gender
1.1 Is the child/young person Aboriginal/Torres Strait Islander?
Was the Aboriginal Child Specialist Advice and Support Service (ACSASS) involved in
the decision to place this child at this time?
Name of ACSASS Worker
Location:
Telephone:
Mobile:
Email
1.2 Does the child/young person identify with any other ethnicity, culture or
religion?
If yes, please specify:
If yes, please also consider Dietary Requirements under Health section.
1.3 What is the child/young person’s first language or preferred means of
communication?
Sign language (if applicable):
First language:
Other Languages:
1.4 If spoken English is not the client’s first language, how well does the child/young
person speak English?
1.5 Current Primary Carer:
Name
Relationship to child/young person
1.6 Child/Young Person’s Current Address:
1.7 Has this child/young person ever been placed in care before?
Refer to 9.0 Placement History for details.
1
{14 Client Name}
1.8 Current Protective Involvement:
Intake date
Current Phase
Substantiated?
Abuse(s): Alleged or Substantiated
1.9 Current Legal Status & Disclosure of Placement
Date
Application/Hearing/Order
Order Expiry Date
{ Application issue
Date}
{Order
Commencement
Date}
Insert current applications
{Application type} orders {Order
type}, hearings {Hearing type}
{Order Expiry}
Placement disclosed
Yes / No
Order Conditions:
1.10 What placement type will best meet the needs of this child/young person?
Refer to 10.0 Summary of important requirements for this placement.
1.11 Is the child/young person part of a sibling group needing placement?
Names of siblings of this child/young person
Name
Also Known As
DHS Client No
DOB & Age
Gender
Is there any reason why this sibling group should not be placed together?
Please state the reason and indicate the preferred placement arrangements?
2.0
BEST INTERESTS PLANNING & PLACEMENT PURPOSE
2.1 Why is this child/young person being placed now?
2.2 Overall best interests planning direction
2
{14 Client Name}
FREE TEXT
2.3 What is the purpose for placement?
2.4 For how long is an out of home care placement likely to be needed?
2.5 Is there an up to date written Statutory Best Interests Plan?
3.0 CHILD/YOUNG PERSON’S CARE & ROUTINES
What other significant information is needed about the child/young person’s routine in order
to give satisfactory immediate care?
3.1 Communication
3.2 Meal times
3.3 Bedtimes
3.4 Leisure
3.5 Selfcare
4.0 HEALTH
4.1 Medicare number
4.2 Health Care Card number
4.3 Health Alerts
Alert
Management/Treatment
4.4 Health Conditions and Disabilities
3
{14 Client Name}
Condition
Age Identified
Year Ceased
4.5 Details of conditions
{88 Details of conditions}
Treatment Please specify current treatment including medications and how they are administered (eg
frequency & type [oral, syringe]).
4.6 Are there any outstanding medical or dental appointments?
Name
Address
Telephone
Type of appointment
Date of Appointment and time
4.7 Are there any outstanding conditions likely to require medical or dental appointments
within 2 weeks of placement?
Condition
4.8 Does the child/young person have specific dietary requirements?
Please include dietary needs/restrictions for health or religious reasons (refer to 1.2) or through their own
choice e.g. young person might choose to be vegetarian.
4.9 Does the child/young person currently use any aids or appliances?
Aid/Appliance Description
Year Commenced
4.10 Does the child/young person wet the bed?
4
5.0 EMOTIONAL and BEHAVIOURAL DEVELOPMENT
{14 Client Name}
5.1 Does the child/young person display any behaviour(s) that has been of a concern to his or
her parents or other carers now or in the past?
5.2 Please describe these behaviours, including triggers and frequency.
5.3 How are these behaviours managed?
6.0 EDUCATION
6. 1 What is the current child care/preschool/school attended?
Name:
Type of School:
Address:
Phone:
Name:
Type of School:
Address:
Phone:
1
6.2 What is the current level/grade the child/young person is completing?
6.3 Current Education /Child Care/Pre-school Contact
Name
Role
6.4 Attendance
Please outline details of days/sessions attended OR reasons not currently attending.
{115 Details of attendance}
6.7 Has the childcare centre/preschool/school been advised that the child/young person is
being placed in out of home care?
1
Only IF >1 record meets criteria, repeat labels and print all records (Fields 112 – 116 only)
5
{14 Client Name}
7.0 FAMILY and SOCIAL RELATIONSHIPS
7.1 Family & Social Network
Please add details of other significant people in the network not in the list below.
Name
Client
Age/DOB
Gender
Relationship
to child/ End
Date
Address & Phone No.
7.2 Contact and Access Arrangements
A. People who have access arrangements with the child/young person
Name
Relationship
Contact
Allowed
Contact Type
Police Check
Frequency
B. People who have been prohibited access to the child/young person
Name
Relationship
Address
7.3 Current Court Orders & conditions associated with contact and access
Court Order
Start
Relevant Conditions
7.4 What immediate arrangements have been made for contact?
Name
Date
Day
Place
Time
Frequency
7.5 Does the child/young person want anyone else to know where they are?
If so who?
If so, has this person been contacted yet?
8.0 PROFESSIONAL INVOLVEMENT
8.4 Other Professionals Involved
Name
Agency, Address & Phone
No.
Role
Start
End
Start
End
Additional Professionals not listed in above table
Name
9.0
Agency, Address & Phone
No.
Role
PLACEMENT HISTORY
Placement Type
Address
Start
End
Reason Placement Started
6
{14 Client Name}
10.0 SUMMARY OF IMPORTANT REQUIREMENTS FOR THIS PLACEMENT
What are the most critical requirements for the care of this child/young person?
7