Documente Academic
Documente Profesional
Documente Cultură
Form
1292
Important Please read this information carefully before you complete this referral. Once you have completed the referral we strongly advise that you keep a copy for your records.
The departments CCS contract managers will assess the eligibility of cases referred to the program and engage the most appropriate service provider to deliver the required services.
Client consent
The clients consent is required for assistance to be provided through the CCS program. This consent covers: making the referral to the CCS program; provision of CCS services to the client(s); provision to the department of the clients personal information on the form; and the ability of the department, its service providers and other agencies to use and disclose the client(s) personal information where that use or disclosure is directly relevant to the provisions of the CCS program and its services. The department will only collect and disclose personal information for a lawful purpose directly related to the provision of CCS services. To enable us to meet these obligations we ask that you obtain the clients consent and get them to sign the form at Question 9 before referring them to CCS. The department will take reasonable steps to ensure that personal information provided in a referral to CCS is disclosed to a CCS service provider in accordance with the Information Privacy Principles and the Privacy Act 1988. The client will be informed of the outcome of the referral. If you wish to be informed about the outcome of the clients referral to CCS, please obtain the clients consent for you to be notified about the outcome. The information form 993i Safeguarding your personal information, available from offices of the department, gives details about the agencies to which personal information might be disclosed. This form is available from the departments website www.immi.gov.au/allforms
Electronic communications
The Australian Government accepts no responsibility for the security or integrity of any information sent to the department over the internet or by other electronic means.
E-mail contact
ccs@immi.gov.au
www.immi.gov.au
Telephone 131 881 during business hours in Australia to speak to an operator (recorded information available outside these hours). If you are outside Australia, please contact your nearest Australian mission.
Form
1292
Attention:
State/territory Date
Client consent
5
Has this referral been discussed with, and agreed to, by the client? No Yes
Has the referral been discussed and agreed to by their parent or legal guardian? No Yes
Address
Is the client happy for you to be notified of the result of their assessment for CCS services? No Only the client will be notified of the result of their assessment
POSTCODE
Contact details Name Telephone number Fax number Mobile/cell E-mail address
Yes
9
(AREA CODE (AREA CODE ) )
Date Note: The clients signature is required for the referral to be considered.
Is your organisation a: (Tick all that apply) CCS service provider HSS service provider SGP service provider Government agency Community organisation Other Give details
DAY MONTH YEAR
Clients details
10 Primary client
Family name Given names
24 Number the issues currently impacting on the client and their family
in order of severity and risk to the client and family members. The most severe risk should be numbered 1.
POSTCODE
Please expand on these issues and risks in Questions 25 to 28. Issue currently impacting Accommodation, homelessness Mental health, emotional well-being (eg. stress, anxiety) Physical health, disability Family and/or relationship breakdown Number
(AREA CODE
Domestic or family violence Child welfare concerns (eg. abuse, neglect) Behavioural concerns (eg. risky, anti-social behaviour) 203 204 Social isolation, lack of support networks Limited life skills or orientation to services
DAY MONTH YEAR
Financial hardship Legal issues Substance abuse Employment difculties Other (please specify)
20 Is an interpreter required?
No Yes Primary language Alternative language Number of adults Number of children
25 Describe the reasons for referral, including the background and current circumstances of the client/family
28 What are the risks to the client/family if CCS services are not provided?
30 Please indicate whether the client/family has received, or is currently receiving, any of the following settlement services:
Settlement service Humanitarian Settlement Services (HSS)
FROM
Name and/or contact details of organisation and services delivered to date (if known)
TO
FROM
TO
FROM
TO