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Stronger Families Referral

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This field is for validation purposes and should be left unchanged.

Family Information:

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Gender - please specify

Aboriginal(Required)

(Clan/LanguageGroup)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Alt phone number:

Best time to contact:(Required)

Other Agencies/Services Involved:

Agency

Contact person

First Last

Role

Contact no.

Referral Information

What are the Referral concerns for the children?(Required)

What are the Referral concerns for the caregiver/s(Required)

What does the family do well?(Required)

What are the positive outcomes others want for this family?(Required)

Culture(Required)

(What role does culture play for the family; what supports, if any, does the family need to connect to culture; what cultural background does the family come from eg language group?)

Client’s views on the issues listed in the referral: (in the client’s own words)(Required)

Client’s views on receiving AFSS Stronger Families service: (in the client’s own words)(Required)

We agree to the following(Required)

To work with my AFSS case worker on the issues that have been identified
To develop a plan with my caseworker about what our family needs help with
To work on carrying out my plan
To keep in regular touch with my caseworker about how I am going
To allow my caseworker into my home
To ensure that my caseworker is safe when they are visiting me
To give my permission to share my personal information (as relevant, as specified, and as needed) with other agencies so that AFSS can give me the best possible service.
I have signed an Authority to Share Information Form(s) and understand that further sharing of information might be needed in future. I understand that my permission for this will be sought then.
I understand that because of legal requirements there might be circumstances where information about me or members of my family might be shared without my consent.
I understand that AFSS is required to provide data to DHS. I understand this data will not include indentifying information such as names, address etc, but does include general data about the support being provided, referrals and nature of concerns.
I will let AFSS know of any dangers that might develop that could threaten the safety of myself or others.
I also understand that my involvement with AFSS is voluntary and that I am free to withdraw my consent at any time.

I Agree to the above statements

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Stronger Families Referral

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Family Information:

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Referral Information

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