Mediation Establishment Form

Child/ren

Number of Children

Relationship to Children

Child 1

Name

Gender

Date of Birth

Child 2

Name

Gender

Date of Birth

Child 3

Name

Gender

Date of Birth

Child 4

Name

Gender

Date of Birth

Child 5

Name

Gender

Date of Birth

Child 6

Name

Gender

Date of Birth

Child 7

Name

Gender

Date of Birth

Child 8

Name

Gender

Date of Birth

Child 9

Name

Gender

Date of Birth

Child 10

Name

Gender

Date of Birth

Other Party's Details

Name

Date of Birth

Relationship to Children

Mobile

Unknown Address

NoYes

Street

City

Postcode

State

Is other party aware of mediation being initiated

NoYes

Are you responding to an invitation for mediation?

NoYes

CatholicCare Consent

Your Right to Privacy
CatholicCare respects your privacy and ensures that any personal information we obtain about you is safeguarded and accessed only by authorised CatholicCare personnel. Your personal information is also protected by law, which CatholicCare is committed to upholding. You can find more information about the relevant privacy legislation and how CatholicCare manages your personal information in our Privacy Policy at www.catholiccare.services or by calling 1300 477 433.
Use and Storage of Personal Information
The information you provide to us includes personal information. CatholicCare ensures your personal information is protected, which includes entering and storing your information into CSnet® (a secure electronic client database). We use your personal information to assist us in providing services to you that best meet your individual circumstances.
We will not share your personal information with anyone else without your consent unless we are required or legally permitted to. For example, we may be required to notify relevant authorities or others in the following circumstances:
if we become aware of actual or intended harm (including dangerous self-harm)
if we receive information about child abuse or risk of abuse
to report the commission, or prevent the likely commission, of an offence involving violence or threat of violence to a person, or of intentional damage to property.
Government Reporting Requirements
The services you will be receiving are partially funded by the Australian Government’s Department of Social Services (DSS). DSS requests personal information about clients who access these services from CatholicCare. With your consent, we provide the required information to DSS via a secure electronic portal called the Data Exchange or “DEX”. Please note: DSS is only able to access de-identified information from DEX, which means your privacy is protected. You can find more information about how DSS manages data and upholds its legal privacy obligations at www.dss.gov.au.
** If you would prefer to access this service from CatholicCare on a private (fee-paying) basis then we will not be required to report any information about you to government departments or other funding bodies. Please review our Fee Statement for detailed information about what fees will apply in these circumstances.

I understand the information above and I have read and understand the information contained in this document and the Client Information Pack. *

I consent to the collection of my personal information by CatholicCare and to my information being used as stated in this document. *

I confirm I give my consent voluntarily and I understand that I can withdraw my consent at any time. *

I consent to my personal information being stored on the electronic database, CSnet®, and to be used for service delivery purposes. *

I consent to my personal information being provided to Department of Social Services via the DSS Data Exchange (Dex). Please note Department of Social Services only have access to information that is de-identified. Please note if you do not consent to this condition you may be charged full fees per CatholicCare fee scale.

consent to CatholicCare contacting me in the future for follow-up evaluation or research purposes.

Measuring Our Impact

For CatholicCare to assist you in the best way possible, we will be monitoring your journey with us along the way.
This is a self-appraisal of how you are ‘at the moment’. It will only take a couple of minutes to fill in but will be an invaluable tool for us to assist you through the process and to ensure we are providing the best service to our clients. We are measuring the impact of our service on your independence, participation and wellbeing and your satisfaction with our service.
Rate how satisfied you are with the following:

1. Your current mental health and wellbeing?

2. Feeling you and/or your children are safe?

3. Feeling satisfied with the way your family is functioning?

4. Your ability to change your behaviour to reduce conflict?

5. Your ability to make your own decisions?

6. Your ability to engage with support services if required?

7. Your ability to cope with the impact of the immediate crisis?

8. Your knowledge and access to information about Family Law?

9. Your skill to manage conflict?

Generate a new image Play the audio code

Enter the code from the image

Client Detail

Residential Address

Postal Address

Client Demographics

Child/ren

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Child 7

Child 8

Child 9

Child 10

Other Party's Details

CatholicCare Consent

Measuring Our Impact