Referral Fill the following referral form to submit or pre-fill a pdf from or you can download a blank form here. Referral Form aMaze is a parenting support program delivered to the communities of Bunbury and Collie and within the Greater Bunbury region. It is aimed at improving children’s development and wellbeing and supporting the capacity of those in a parenting role. The program model based on evidence-based practice and programmes, to support all domains of family life including: Physical Health; Relationships; Material Wellbeing; Learning and Development; Safety; and Spirituality. REFERAL INFORMATION Parent Participant ("Client") of aMaze program: Name DOB Sex MaleFemale Address Phone Email Address Agency/Service Provider/Health Professional making Referral: Name Position Organisation Address Phone Fax Email Address Consent for Referral: Has the parent/family given consent for this referral to be made? (Please note this is not mandatory ) Yes No Consent for Release of Information Has the client provided consent for the release of information between our services? Yes (Client to sign below; or Professional Declaration of Verbal Consent) No Reason for Referral (as applicable to Physical Health; Relationships; Material Wellbeing; Learning and Development; Safety and Spirituality). Reason for Referral Record of Written Consent As an addition to this referral being made by: Name from I also give consent for information about my family and situation to be shared between these two organisations to ensure that services continue to meet my needs. Name of person (client) giving consent Signature of person giving consent signature keyboard Clear Record of Verbal Consent (Agency/Service Provider/Health Professional seeking consent) Verbal consent should only be used where it is not practicable to obtain written consent I have discussed the proposed referrals with the client. I am satisfied that the client understands the proposed uses and disclosures, and has provided their informed consent to these. Signature signature keyboard Clear Date Name Organisation Role
