LILLY PILLY INTAKE FORM

PERSONAL INFORMATION

Information provided in this form is treated as CONFIDENTIAL

Please select option:
Person being supervisedPerson with whom child/ren reside
Name:

Address:

Mobile:

Email Address:

Emergency contact name:

Emergency contact number:

Legal representative's name / firm / self rep:

Legal representative Phone number:

Legal representative Email:

CHILD/REN DETAILS

Number of child/ren to be supervised:

Relationship to person being supervised:

How long since child/ren have seen or spoken with the Supervised Parent:

CHILD 1
Name:

Gender:

DOB:

Age:

Vaccinations up to date:
yesno
Legal representative (ICL):

CHILD 2
Name:

Gender:

DOB:

Age:

Vaccinations up to date:
yesno
Legal representative (ICL):

CHILD 3
Name:

Gender:

DOB:

Age:

Vaccinations up to date:
yesno
Legal representative (ICL):

Behavioural notes/concerns (ICL):

Medical information (e.g. allergies):

REQUESTED VISIT DETAILS

Starting date:

List all dates OR Specify frequency (i.e. weekly, fortnightly):

Finish date OR blank if ongoing:

Visits start and finish time (excluding transport):

Transport to and from venue required?:
yesno
Transport additional details:

Contact venue/s :

Attendees (List all attendees):

Domestic Violence Orders:
yesno
If "yes" please attach file:

Family / Federal CC Orders?:
yesno
If "yes" please attach file:

Parenting Plan (signed by both parties)?:
yesno
If "yes" please attach file:

Are you responsible for payment of the service:
yesno
If "yes" please percentage (or dollar amount) of responsibility:

Additional information that may assist the supervisor :

ALL COSTS ARE PAYABLE BEFORE SCHEDULED SUPERVISED CONTACT OR OTHER SERVICES

SERVICE AGREEMENT

All service users must complete and sign this form

This Agreement is a contract between you and Lilly Pilly. The information and terms in this document apply to your use
of our services. In signing this document you agree that you will be bound by the terms and conditions in this
Agreement. If you do not want to be bound by this Agreement, you must stop using our Services.
We may amend this Agreement at any time, for example if we update the operation of our Services or as required by
law. All future changes included in a policy update are incorporated by reference into this agreement.
If we make significant changes to this Agreement which may impact on your use of our services or our service provision,
we will email you an updated copy of the Lilly Pilly Service Agreement for your records.
Any changes to the Lilly Pilly Service Agreement will take effect 30 days after the updated Agreement has been
provided.

By continuing to use our Services after any amendments to this Agreement, you agree to abide and be bound by any
changes. If you do not agree with any changes we make to this Agreement, you may terminate this Agreement by
terminating use of this service.

I agree to the following:

1. I understand that all court order directions shall be strictly adhered.
2. I have read and agree to the Lilly Pilly terms and conditions for service use outlined in the Lilly Pilly Service
Agreement.
3. I agree that the information provided in this form is correct and any changes/ additional dates will need to be
approved by both parties and sent in writing to Lilly Pilly.
4. I agree that changes to this Intake Form without prior approval from the other party may incur an
administration fee, invoiced to the person responsible for attempted changes.
5. I understand whilst at Lilly Pilly I may be under video and sound recording.
6. I acknowledge that this information provided to Lilly Pilly does not hold privilege in court, and that Lilly Pilly
may in certain limited circumstances be required, whether by law, court order or government authority,
disclose parts of, or all, information held in your file.
7. I understand there may be other children and adults at the centre during the period of visits.

CONDUCT

1. If the child/ren or I are unable to attend contact for any reason, I will inform Lilly Pilly as soon as possible. I
understand it is my responsibility to inform the other party through relevant legal channels. I am aware that a
late cancellation fee will be incurred if I cancel after 5pm of the weekday before my contact visit.
2. I will comply with the agreed arrangements.
3. I will comply with the reasonable directions of the Contact Supervisor.
4. I will not come to the contact visit under the influence of drugs or alcohol, nor partake in the consumption of
drugs or alcohol during the contact.
5. I will not be aggressive or abusive towards Lilly Pilly personnel prior to, during or after the contact visit.
6. If I feel that I am getting distressed or upset at any point during the contact visit, I will step away to collect
myself.
7. I am aware that my contact visit can be cancelled if I do not abide by any of the above points.
8. In relation to any additional attendees, I will advise Lilly Pilly in advance of the contact visit. Any attendees
NOT approved to attend must be listed on the Referral Form following agreement from both parties.

CLIENT DISCLAIMER

1. I agree that the information provided to Lilly Pilly is true and correct to the best of my knowledge and belief.
2. I agree, as a condition of participating in any activity supervised by Lilly Pilly and its Contact Supervisors, I
release and indemnify Lilly Pilly from and against any liability arising directly or indirectly out of such
participation (including negligence).
3. To the fullest extent permitted by law, the Indemnity covers, but is not limited to, any liability arising out of,
or as a direct or indirect consequence of any harm, loss, damage, bodily injury or death sustained
by myself, my child/ren and any attendees as a result of participation in the activities (including transportation
of children/attendees to and from such activities), or being present at a premises utilised by Lilly Pilly for the
purpose of Contact Supervisory services or handovers.

I have read Lilly Pillys Intake & service agreement

Print Name:

Date:

Signature:
Clear

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