CYFS Intake Form

Your Data, Your Choice

The information that you provide will be used to create your file, provide effective service and help us contact you.

Privacy –CCA is committed to respecting your privacy. All personal information is handled in compliance with Australian privacy law. For more details on how we collect, use and disclose personal information please read our Privacy Policy available on our website or in hard copy in our offices. https://www.ccas.org.au/privacy-policy/

Confidentiality – All staff sign a Confidentiality Agreement. State and Federal legislation requires staff to notify the relevant authority if they reasonably believe that a person’s health and safety, or that of the public, is at risk.

Research – De-identified data is used for research and evaluation purposes, including compiling statistics to guide us and our funders on how to improve our services.

Counselling Declaration – All information is kept confidential and stored securely in accordance with legislation. Unidentified data is compiled for funding reports. You are free to access your file upon requests. You are free to ask questions or make complaints about the service you have received. No referrals or information will be shared without your consent. Further information regarding the above mentioned can be found in our policies that can be supplied upon your request.

School/Location

Service/Program Name

YOUR DETAILS

First Name

Last Name

Home Address

Street

Suburb

Postal Code

State

Country

Is your Mailing Address the same as your residential address?

YesNo

Mailing Address

Mailing Street

Mailing Suburb

Mailing Postal Code

Mailing State

Mailing Country

Are you accessing CCA Counselling Service?

YesNo

Do you consent to being contacted by us at a later date to participate in follow- up evaluation and /or research at under CCA? Please note: You can withdraw your consent at any time. The information you provide will help us create services and programs that best suit our clients in NSW, as well as meet our Commonwealth and State funding requirements.

YesNo

Do you consent for CCA to store your personal information for reporting on Data Exchange, A system hosted by the Australian Government Department of Social Services (DSS)? Please note: You can withdraw your consent at any time.

YesNo

Contact Information

City of Parramatta Libraries	Health Agency	Community Services Agency
School/ Education Agency	Employment/ Job Placement Agency	Family
Centrelink/Dept. of Human Services	Friends/Colleague	Medical Practitioner
Internet	Website	Social Media
Flyer	Newspaper	Other (please specify):

Aboriginal	Torres Strait Islander	Aboriginal and Torres Strait Islander
Neither Aboriginal nor Torres Strait Islander	Not stated/inadequately described

Pre-primary School	Primary School	High School
Certificate	Diploma/Advanced diploma level	Bachelor Degree
Postgraduate	Grad. Diploma/Grad. Certificate	Other Education

Paid Full-Time	Paid Part - Time	Unpaid/Volunteer
Unemployed and looking for work	Unemployed and not looking for work	Studying full – time
Studying part - time	Caring	Parenting

Couple	Couple + dependants	Single
Sole parent + dependents	Unrelated adults	Related adults
Homeless right now	I would prefer not to answer

Mental health, wellbeing and self-care	Personal and family safety	Age-appropriate development
Community participation and networks	Family functioning	Education and skills training

City of Parramatta Libraries	Community services agency	Education agency
Legal agency	Other Agency	Internal
Self	Family	Friends
General Medical Practitioner	Not stated/inadequately described

Sensory/ Speach	Physical/ Diverse	Intellectual/ Learning
Psychiatric	None	Not Stated/ Inadequately Described

Trauma	Family violence
Bullying or school issues	Relationship/family issues
Substance abuse	Disengaged
Low mood	Anxiety
Risk taking behaviours	Mental health
Anger issues	Other