Confidential Parent Referral Form printable pdf download

Confidential Parent Referral Form

School Chaplain / Student Welfare Worker

Funded through the National School Chaplaincy and Student Welfare Program funded by DEEWR

Please complete this form and return to the Office

PERSONAL DETAILS:

Student’s Name: ______________________________________________________________________

DOB: ______________________ Gender M / F Main Language Spoken at Home: _________________

Teacher: _____________________________________________________ Class: _________________

Mother’s/Guardian’s Details

Name:

_____________________________________________________________________________

Address: _____________________________________________________________________________

______________________________________ Postcode: _____________________________

Best contact name and time during the day: ________________________________________________

Others residing at the above address (including siblings and their DOB’s):

_____________________________________________________________________________________

____________________________________________________________________________________

Father’s/Guardian’s Details

Name:

_____________________________________________________________________________

Address: _____________________________________________________________________________

______________________________________ Postcode: _____________________________

Best contact name and time during the day: ________________________________________________

Others residing at the above address (including siblings and their DOB’s):

_____________________________________________________________________________________

Chaplains work in partnership with schools, parents and other service providers. Some of the services that may be

provided for your child are:



Group or individual counselling



Social/emotional support and skills building programs

Parent/Guardian Consent:

I understand that the School Chaplain/Student Welfare Worker carries out counselling and support services.

I consent to my child being seen by the School Chaplain/Student Welfare Worker. Yes / No

I consent to the exchange of relevant information with other agencies that are/have been involved. Yes / No

Signed: (Mother/Guardian): ___________________________________ Date: ___________________________

(Father/Guardian): ____________________________________ Date: ____________________________

Confidential Parent Referral Form