t +61 2 9219 2002

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Triple Care Farm Application Form

Are you looking for:(*)

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Client Contact Details
First Name(*)
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Last Name(*)
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Phone Number(*)
Please enter a valid mobile number or phone number with area code e.g. 0414 111 111 OR (02) 9212 2002

Enter mobile or phone number 0414 111 111 or 02 9212 2002

Email address(*)
Please add a valid email address.

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Current address
Please enter your address

Please enter full address, including State and Postcode

Date of birth(*)
If your birthday is 3rd May 1994, type 03/05/1994

DD/MM/YYYY

Age(*)
e.g. 19

Is this the first admission to TCF and/or DMP?(*)
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If no, how many times have you/they been to TCF
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Do you/they have problematic drug or alcohol use?
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Please specify
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Personal Details
Country of Birth(*)
e.g. Australia

Preferred Language(*)
e.g. English

Aboriginal or Torres Strait Islander(*)
Please choose yes or no

Non English Speaking Background(*)
Please choose yes or no

Requires an Interpreter(*)
Please choose yes or no

Language
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Do you/they have any disabilities?(*)
Please choose yes or no

Please specify
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Gender Details
Current Gender Identity(*)
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Please State Identity
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Gender Assigned at Birth(*)
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Are you Intersex(*)
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Sexual Orientation(*)
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Please state identity
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Details of Referrer
Type of Referral(*)
Please choose an option

I am referring myself
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Referrer’s Name(*)
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(If you are referring yourself, put ‘myself’)

Agency/Relationship to client(*)
e.g. myself, mother, friend

e.g. FACS, mother, friend (If you are referring yourself, put ‘myself’)

Email address(*)
Please enter a valid email address

Phone(*)
Please enter a valid phone number with area code e.g. 02 9212 2002, or a mobile e.g. 0414 123 123

Address

Please enter full address, including State and Postcode

 
Details of Referrer Continued
Family and Community Services(*)
Please select and Option

Are you working with Family and Community Services

Name of Case Worker
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Phone Number
Please enter a valid phone number with area code e.g. 02 9212 2002, or a mobile e.g. 0414 123 123

Email address
Please add a valid email address.

Juvenile Justice(*)
Please select an Option

Are you working with Juvenile Justice

Name of Juvenile Justice Officer
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Phone Number
Please enter a valid phone number with area code e.g. 02 9212 2002, or a mobile e.g. 0414 123 123

Email address
Please add a valid email address.

 
Care Status
Care Status(*)
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Complete relevant carer details below:

Name of Mother
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Phone Number
Please enter a valid phone number with area code e.g. 02 9212 2002, or a mobile e.g. 0414 123 123

Mother's Address
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Name of Father
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Phone Number
Please enter a valid phone number with area code e.g. 02 9212 2002, or a mobile e.g. 0414 123 123

Father's Address
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Name of Guardian
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Phone Number
Please enter a valid phone number with area code e.g. 02 9212 2002, or a mobile e.g. 0414 123 123

Guardian's Address
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Relationship with Client
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Emergency or Exit Contact
Legal Guardian or Emergency Contact Name(*)
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Please provide their first and last names

Phone Number(*)
Please enter a valid phone number with area code e.g. 02 9212 2002, or a mobile e.g. 0414 123 123

Address
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Relationship to Client
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Secondary Contact Name (if Guardian/Emergency Contact is unavailable)
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Phone Number
Please enter a valid phone number with area code e.g. 02 9212 2002, or a mobile e.g. 0414 123 123

Address
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Relationship to Client
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Identification Information
Medicare Number
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Medicare Card Expiry
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Medicare Reference Number
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(This is the number that appears to the left of your name on your Medicare Card)

Tax File Number
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Do you/they have a birth certificate?
Please choose yes or no

 
Medical Information
Significant medical conditions e.g. allergies, asthma, diagnosed mental health conditions
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Ongoing prescribed medication
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Any known Allergies?
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Please specify Details and Reaction
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Hospital admission for Mental Health within last 2 years(*)
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If yes, please provide a copy of the hospital discharge summary. Failure to provide will delay admittance to the program.

Do you have a Community Treatment Order?(*)
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If yes, please provide a copy of the Order. Failure to provide will delay admittance to the program.

 
Income Status
Income Status (tick all that apply)

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Please specify
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Education and Training
Last Grade Completed at School
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Reason for leaving/general comments
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Have you/they completed any vocational training
Please choose yes or no

Please specify
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Background
Physically Abused(*)
Please choose an option

Sexually Abused(*)
Please choose an option

Attempted suicide(*)
Please choose an option

Please comment
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Problems with drug use(*)
Please choose an option

Problems with alcohol use(*)
Please choose an option

Problems with gambling(*)
Please choose an option

If yes to any, please comment
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Do you/they have any current police charges?(*)
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Please list current charge details
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Comments (e.g. outstanding matters, court dates, fines)
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Do you/they have a Criminal History(*)
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If yes, please provide a copy of criminal history. Failure to will delay admittance to the program.

Any acts of aggression/violence in the criminal history? (*)
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If yes, please provide police facts. Failure to provide will delay admittance to the program.

 
Family Background
Family details including notable family history and details about siblings
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Community Support
Support from Community-based Worker(*)
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Have you/they received support from a community-based worker of any kind (e.g Juvenile Justice officer, Probation & Parole officer, mental health worker, GP support, counsellor, mentor, social worker or case manager)?*

I understand I need a 2C Risk Assessment Form(*)
Please confirm that you understand by clicking Yes

Please note the 2C Risk Assessment Form needs to be completed by the most relevant support worker and sent to the TCF Intake Coordinator in addition to this online referral form. Failure to do so will slow down the application process.

 
Confirmation
Declaration(*)
You need to confirm the information to proceed.

I confirm that, to the best of my knowledge, all information on this application form is correct

Let us know you are a real person
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Date(*)

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Signed(*)
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By entering your full name, you have electronically signed this form.