Mums and Bubs Referral Form

Thank you for referring to Windermere's Mums and Bubs Program.

The referral form must be completed by an authorised referrer and will be submitted to our program for assessment. The form is to capture as much relevant information as possible and forms one part of our intensive assessment process.

1. Your Details

Organisation *

Given name(s) *

Surname *

Direct phone number *

Secondary phone number

Email address *

Current support being provided by your organisation *

Are there other organisations/agencies involved? *

YesNo

Organisation *

Contact name *

Contact number *

Purpose of support *

Is there another organisation/agency involved? *

YesNo

Organisation *

Contact name *

Contact number *

Purpose of support *

Is there another organisation/agency involved? *

YesNo

Organisation *

Contact name *

Contact number *

Purpose of support *

2. Mother's Details

Title

Preferred Pronouns

Given name(s) *

Surname *

Date of birth *

Country of birth *

Age *

Gender *

MaleFemaleNon-identified

Is the mother of Aboriginal or Torres Strait Islander origin? *

YesNo

Main language spoken at home *

Interpreter required? *

YesNo

Mobile phone *

Email address *

My preferred contact method is: *

EmailMobileHome Phone

Please upload a copy of the mother's driver's licence or alternative form of ID *

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Please upload a copy of the mother's Centrelink Income Statement

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You can access this by logging into your Centrelink account via the MyGov website.

3. Child's Details

Given name(s) *

Surname *

Date of birth *

Country of birth *

Age *

Gender *

MaleFemaleNon-identified

Is the child of Aboriginal or Torres Strait Islander origin? *

YesNo

Main language spoken at home *

4. Current Accommodation

Street address *

Postcode *

Type of accommodation *

Who are they living with? *

How long have they been there? *

How long can they stay? *

Why do they need to leave? *

5. Financial

What income does the mother receive? *Payment type

How much are they receiving per fortnight? *

Are there any foreseeable changes to their income? *

YesNo

What type of changes? *

6. Transport

Does the consumer have their licence? *

YesNoLearners

Does the consumer have a car? *

YesNo

7. Consumer Understanding

Has the consumer been informed of their referral to the Mums and Bubs program? *

YesNo

What is their understanding of and expectations from the Mums and Bubs program? *

Is the consumer willing to search for Private Rental as their exit pathway? *

YesNo

Is the consumer willing to participate in all scheduled house activities and groups? *

YesNo

8. Health

Does the mother have any physical or mental health issues, disability or impairment? *

YesNo

Please provide details *

Does the child have any physical or mental health issues, disability or impairment? *

YesNo

Please provide details *

9. Family History

Please provide some details about the mother’s family of origin. Who does the mother have contact with? Are the relationships supportive or destructive? *

Please provide details about the child’s father. Is he in contact with the mother and child? What are the characteristics of this relationship? *

10. Family Violence

Is the mother and/or child a victim survivor of family violence? *

YesNo

Please provide details *

Has a MARAM been completed in the last three months? *

YesNo

Please upload a copy of the MARAM

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11. Legal

Is there an IVO in place? *

YesNo

Please upload a copy of the IVO

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Please provide details *

Are there any other outstanding legal issues? *

YesNo

Please provide details *

12. Child Safety

Is there current Child Protection involvement with the family? *

YesNo

Reasons for involvement *

Is there a voluntary agreement in place? *

YesNo

Is there a court order in place? *

YesNo

What conditions does the mother have to comply with? *

Are there any current concerns for the child’s safety? *

YesNo

Please provide details *

13. Risks

Has the consumer engaged in or at risk of self-harm? *

YesNo

Please provide details *

Has the consumer ever expressed suicidal ideation or attempted suicide? *

YesNo

Please provide details *

Has the consumer ever struggled to manage their anger? *

YesNo

Please provide details *

Does the consumer have any history or current concerns with substance misuse? *

YesNo

Please provide details *

Are you aware of any risks/issues that would impact on this consumer’s ability to live in a shared accommodation program with other young women and their children? *

YesNo

Please provide details *

14. Education & Training

What is the highest level of education the consumer has achieved? *

Is the consumer currently enrolled in any education? *

YesNo

Please provide details (including course type, location, attendance day and times etc.) *

Would the consumer like to engage in further education? *

YesNo

What course or area of study are they interested in? *

15. Employment

Is the consumer currently engaged in employment? *

YesNo

Please provide details *

Has the consumer previously engaged in employment? *

YesNo

Please provide details (including timeframe and reason for leaving) *

Would the consumer like to engage in employment in the future? *

YesNo

What industry or job are they interested in? *

16. Family Routine

Please tell us about any regular activities the family engage in (e.g. playgroup) as well as their day-to-day routine and the child’s feeding and sleeping times. Is the consumer able to maintain a consistent routine? *

16. Goals & Plans

What goals does the consumer have for their time at Mums and Bubs and into the future? *

What skills would the consumer like to work on at Mums and Bubs? (e.g. cooking, housekeeping, budgeting, attachment to child, family routine, organisation, private rental, parenting support etc.) *

What is the consumer’s first priority if they are accepted to Mums and Bubs? (eg. cooking, housekeeping, budgeting, attachment to child, family routine, organisation, private rental, parenting support etc.) *

17. Declaration

I hereby declare that the information given in this form is true and correct to the best of my knowledge/belief *

I have read and understand Windermere's Privacy Policy here *

Please sign here *

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Use your finger, stylus or mouse to draw your signature in the field above.

Name *

Date *

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