CAP Referral Form

FCAV Carer Assistance Program Referral Form

Please complete this referral form to be contacted directly by the CAP team with an appointment.

Please note that the CAP service is unable to provide immediate crisis support. For urgent issues related to an immediate risk of harm to yourself or others, please refer to our Emergency Contacts/Support page.

First Name *

Last Name *

Email Address *

Phone number *

Address

Street addressStreet address line 2

City

State

Postcode

Country

I am a... *

Accredited Foster CarerPermanent CarerSpecial Needs Adoptive ParentFamily Law Court Ordered Carer

Please select all that apply. Please note that Kinship Carers with Children’s Court Orders are not eligible for CAP, but are encouraged to contact Kinship Carers Victoria on 0499 969 234, or the Carers Gateway on 1800 422 737.

Agency

What year were you accredited

What year was your Permanent Care Order formalised?

If you have selected more than one type of care could you please nominate the type of care this referral primarily relates to

Are you Aboriginal and/or Torres Strait Islander?

YesNoPrefer not to say

Are any of the children in your care Aboriginal and/or Torres Strait Islander?

YesNoPrefer not to say

Is there anything else we should know so we can support you in a way that feels safe, respectful, and helpful?

How many children are currently in your care?

Reason for Referral? (Brief summary of issues) * *

What do you hope to get out of the CAP support?

Preferred appointment day * *

MondayTuesdayThursdayFriday

Preferred appointment time?* *

Morning Afternoon

Preferred contact method *

Phone callVideo call

Who has submitted this referral* *

Self referredAgencyFCAVPCA FamiliesOther

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