Nazareth Family Support Referral Form

ACKNOWLEDGEMENT*

I understand that this is not an emergency service, and by proceeding I acknowledge that although the referral will be responded to within a timely manner, response times may vary. For urgent school related matters, please contact the College on 8406 5300. For crisis support or urgent medical assistance, please call 000 or present at your local hospital.
Who is Referring
Select*
Role at Nazareth*
Your details
First name*
Last name*
Contact number*
Email*
Enter Email Confirm Email
Referral
I would like support provided for a Nazareth family. I.e. student currently enrolled*
I would like to be contacted about possibly providing support (in the form of meals) to a current/past staff member, past student/family or other member of the Nazareth community*
Please tell us the reason for support?*
Have parents/caregivers been made aware of this referral?*
Student Details
If there are multiple students at Nazareth, please only provide us with the details of one student.
First name*
Last name*
Year level*
Reason for Referral
Family Support may be required at different times for students and families of the Nazareth community, and supports offered to families are available in the following areas. Please indicate which of the following areas are relevant.*
- Access and support with school supplies (eg uniform, stationery)
- Information and referrals to external supports (eg Foodbank)
- Family Support (eg health, accommodation/housing, change in family dynamics)
- Exploring potential financial supports (eg school card)
- Family bereavement/grief
- Advocacy
- Other
Other
Have you spoken to your family about this referral?*
Background Information
Please provide any background information that may help us best assist the family.*
Please provide us with any relevant information about your current situation so we can best assist you and/or your family.*
Is there anything else you would like to share about your family that would help us to provide the best support. Ie, does your family recieve support from anyone else?*
Additional Support
Are there any current external services providing support? I.e. Centrecare, Housing SA, NDIS*
Please provide additional information if known
In addition to Family Support, the Nazareth Counselling Team is available to support our students. Would you like to make a referral to the Nazareth Counselling Team?*
Nazareth Counselling Team
Please complete this form to be contacted by a member of the Nazareth Counselling Team. Click here (opens new tab).
Family and Pastoral Care Coordinator Contact
If there is a preferred day/time for the Family and Pastoral Care Coordinator to make contact to discuss this referral, please provide details.
The best time to contact is:
Is there a preferred time to contact your family to discuss the referral?*
The best time to contact my family is:*
Confidentiality
Maintaining privacy and confidentiality standards are of the utmost importance to our counselling team. For further information on our confidentiality requirements. Click here (opens new tab).
Acknowledgement*

I acknowledge that the information I have provided in this form will be received by the Nazareth Family and Pastoral Care Coordinator, and may be shared with relevant staff members at their discretion. While all information provided within referrals is treated in a respectful and sensitive manner, the sharing of information may at times be necessary in order to meet our duty of care. For further information please click here (opens new tab). The Family and Pastoral Care Coordinator will strive to respond to your referral as soon as possible. Please note that referrals may not be received until the following working day and will not be monitored over weekends and school holiday periods. For urgent school related matters, please contact the College on 8406 5300. For crisis support or urgent medical assistance, please call 000 or present at your local hospital.

Nazareth Family Support Referral Form

Who is Referring

Your details

Referral

Student Details

Reason for Referral

Background Information

Additional Support

Nazareth Counselling Team

Family and Pastoral Care Coordinator Contact

Confidentiality