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Application Form - Supervised Contact Visits
Note: A separate Application Form must be completed by each Applicant
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1
Applicant's Name
*
This field is required.
First Name
Last Name
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2
Applicant's Residential Address
*
This field is required.
Number & Street Name
Street Address Line 2
Suburb
State
Postcode
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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3
Applicant's Email Address
*
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example@example.com
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4
Applicant's Phone Number
*
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Please enter a valid phone number.
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5
Applicant's Nationality
*
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Nationality
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6
Main Language Spoken by Applicant
*
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Applicant's Main Language
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7
Applicant's Relationship to Child/Children
*
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Mother
Father
Grandparent
Foster Parent
Carer
Other
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8
How many Children is this Application for?
*
This field is required.
Please Select
One
Two
Three
Four
Five
Six
More than Six
Please Select
Please Select
One
Two
Three
Four
Five
Six
More than Six
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9
Child 1 - Details
*
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First Name
Last Name
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10
Child 1 - Date of Birth
*
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Date of Birth
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11
Child 1 - Gender
*
This field is required.
Please Select
Male
Female
Non-Binary
Other
Please Select
Please Select
Male
Female
Non-Binary
Other
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12
Does Child 1 have any Disabilities or Additional Needs?
*
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YES
NO
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13
Child 1 - Please provide details of any Disabilities or Additional Needs
*
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14
Child 2 - Details
*
This field is required.
First Name
Last Name
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15
Child 2 - Date of Birth
*
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Date of Birth
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16
Child 2 - Gender
*
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Date of Birth
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17
Does Child 2 have any Disabilities or Additional Needs?
*
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YES
NO
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18
Child 2 - Please provide details of any Disabilities or Additional Needs
*
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19
Child 3 - Details
*
This field is required.
First Name
Last Name
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20
Child 3 - Date of Birth
*
This field is required.
Date of Birth
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21
Child 3 - Gender
*
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Date of Birth
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22
Does Child 3 have any Disabilities or Additional Needs?
*
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YES
NO
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23
Child 3 - Please provide details of any Disabilities or Additional Needs
*
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24
Child 4 - Details
*
This field is required.
First Name
Last Name
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25
Child 4 - Date of Birth
*
This field is required.
Date of Birth
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26
Child 4 - Gender
*
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Date of Birth
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27
Does Child 4 have any Disabilities or Additional Needs?
*
This field is required.
YES
NO
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28
Child 4 - Please provide details of any Disabilities or Additional Needs
*
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29
Child 5 - Details
*
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First Name
Last Name
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30
Child 5 - Date of Birth
*
This field is required.
Date of Birth
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31
Child 5 - Gender
*
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Date of Birth
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32
Does Child 5 have any Disabilities or Additional Needs?
*
This field is required.
YES
NO
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33
Child 5 - Please provide details of any Disabilities or Additional Needs
*
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34
Child 6 - Details
*
This field is required.
First Name
Last Name
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35
Child 6 - Date of Birth
*
This field is required.
Date of Birth
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36
Child 6 - Gender
*
This field is required.
Date of Birth
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37
Does Child 6 have any Disabilities or Additional Needs?
*
This field is required.
YES
NO
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38
Child 6 - Please provide details of any Disabilities or Additional Needs
*
This field is required.
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39
Who does your Child/Children currently live with?
*
This field is required.
Please Select
Mother
Father
Grandparent
Carer
Other
Please Select
Please Select
Mother
Father
Grandparent
Carer
Other
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40
Are there any AVO/ADVO's currently in place?
*
This field is required.
(if YES, a copy will be required to be submitted with this Application Form)
YES
NO
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41
Is there an open DCJ Case for your Child/any of your Children?
*
This field is required.
YES
NO
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42
Details of DCJ Case Worker
Name of DCJ Case Worker
DCJ Case Worker's Phone Number
Case Worker's Email Address (if known)
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43
Do you have a Parenting Plan, Parenting Agreement or any Court Orders?
*
This field is required.
(if YES, a copy will be required to be submitted with this Application Form)
YES
NO
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44
Do you have a Solicitor/Lawyer?
*
This field is required.
YES
NO
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45
Your Solicitor/Lawyer's Details
*
This field is required.
Name of your Solicitor/Lawyer
Name of your Solicitor/Lawyer's Legal Firm (if applicable)
Your Solicitor/Lawyer's Phone Number
Your Solicitor/Lawyer's Email Address (if known)
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46
Does your Child/Children have an Independent Children's Lawyer?
*
This field is required.
YES
NO
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47
Your Child/Children's Independent Lawyer's Details
Name of Independent Children's Lawyer
Name of Independent Children's Lawyer's Legal Firm (if applicable)
Phone Number for Independent Children's Lawyer (if known)
Email Address for Independent Children's Lawyer (if known)
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48
Have you used a Children's Supervised Contact Service previously?
*
This field is required.
YES
NO
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49
Previous Children's Supervised Contact Service Details
Name of Previous Supervised Contact Service
Address of Previous Supervised Contact Service
Phone Number for Previous Supervised Contact Service
Reason for Ceasing Use of Previous Supervised Contact Service
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50
Requested Frequency of Supervised Contact Visits
*
This field is required.
Please Select
Once per week
Twice per week
Three times per week
Once per fortnight
Monthly
Every 2 months
Every 3 months
Every 4 months
Every 6 months
Once a year
Other
Please Select
Please Select
Once per week
Twice per week
Three times per week
Once per fortnight
Monthly
Every 2 months
Every 3 months
Every 4 months
Every 6 months
Once a year
Other
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51
Requested Days for Supervised Contact Visits
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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52
Requested Time for Supervised Contact Visits
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
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12
Hour
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59
AM
PM
AM
AM
PM
Until
1
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2
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Hour
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00
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54
55
56
57
58
59
Minutes
AM
PM
AM
AM
PM
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53
Requested Location/Suburb/Area for Supervised Contact Visits
*
This field is required.
Where would you like Supervised Contact Visits to take place?
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54
Who will be responsible for payment of fees & costs for Supervised Contact?
*
This field is required.
Please Select
Me
Other Parent
Both of us/50:50
Other
Please Select
Please Select
Me
Other Parent
Both of us/50:50
Other
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55
Other Parent/Applicant's Name
*
This field is required.
First Name
Last Name
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56
Other Parent/Applicant's Residential Address (if known)
Number & Street
Street Address Line 2
Suburb
State
Postcode
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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57
Other Parent/Applicant's Email Address (if known)
example@example.com
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58
Other Parent/Applicant's Phone Number (if known)
Please enter a valid phone number.
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59
Other Parent/Applicant's Nationality (if known)
*
This field is required.
Nationality
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60
Other Parent/Applicant's Relationship to Child/Children
*
This field is required.
Mother
Father
Grandparent
Foster Parent
Other
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61
Does the Other Parent/Applicant have a Solicitor/Lawyer?
*
This field is required.
YES
NO
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62
Other Parent's/Applicant's Solicitor/Lawyer's Details (if known)
Name of Other Parent/Applicant's Solicitor/Lawyer (if known)
Name of Other Parent/Applicant's Solicitor/Lawyer's Legal Firm (if applicable)
Phone Number for Other Parent/Applicant's Solicitor/Lawyer (if known)
Email Address for Other Parent/Applicant's Solicitor/Lawyer (if known)
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63
Does the the Other Parent/Applicant know you are applying for Supervised Contact Visits with Hope Family Cottage?
*
This field is required.
YES
NO
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64
Emergency Contact Person's Details
*
This field is required.
If we are unable to contact you in the case of an emergency, who would you like us to contact?
First Name
Last Name
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65
Emergency Contact Person's Residential Address
*
This field is required.
Number & Street
Street Address Line 2
Suburb
State
Postcode
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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66
Emergency Contact Person's Email Address
*
This field is required.
example@example.com
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67
Emergency Contact Person's Phone Number
*
This field is required.
Please enter a valid phone number.
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68
Emergency Contact Person's Relationship to Child/Children
*
This field is required.
Step Mother
Step Father
Carer
Grandparent
Aunty
Uncle
Family Friend
Other
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69
Does the nominated Emergency Contact Person know Hope Family Cottage will be providing Supervised Contact Visits for your child/children?
*
This field is required.
YES
NO
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70
Required Documents & Attachments
*
This field is required.
Please prepare the following documents to be uploaded on the next page as PDF/JPG/JPEG as attachments
Front and back of my photo ID (e.g., drivers' licence).
Copies of any current Parenting Plans, Parenting Agreements or Court Orders (if applicable).
Copies of any current AVO’s/ADVO’s (if applicable).
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71
Upload Required Attachments/Documents Here
*
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Drag and drop files here
Select files to upload
Browse & Upload
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72
Declaration
*
This field is required.
All information I have provided in this Application Form is true and correct to the best of my knowledge.
I understand that Hope Family Cottage may contact my Solicitor/Lawyer and any previous Children’s Contact Service(s) used (if applicable) as part of the Application process.
I understand that Hope Family Cottage does not enter into discussion with the Other Parent/Applicant regarding who is responsible for payment of fees & other costs associated with Supervised Contact Visits. This must be agreed upon prior to submitting this Application Form.
I understand that no services will be provided by Hope Family Cottage without prior payment in full, including the next step in the Application process, which is separate Intake Assessments for both Parents/Applicants.
I understand that Hope Family Cottage reserves the right to refuse an Application for Supervised Contact Visits at it's own discretion at any stage of the Intake process.
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73
Signature of Applicant
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74
Next Step - Intake Assessments
Select either:
'Iniital Intake Assessment' if agreement for payment is Shared/50:50 or 'Initial Intake Assessment' AND 'Initial Intake Assessment 2' if you are responsible for full payment.
Do not complete if agreement is for the other Parent/Applicant to pay ALL fees & costs.
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ORDER SUMMARY
10% GST
AUD
Subtotal
AUD
Total cost
AUD
Initial Intake Assessment
1 Hour Telephone Intake Assessment for Applicant, as required.
$
135.00
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Initial Intake Assessment 2
1 Hour Telephone Intake Assessment for Other Parent/Applicant, as required.
$
135.00
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