Page 91 - Meeting with Children Manual

P a g e | 1 Referral and Release of Information

File Number ________________________

Dear _____________________

Re: Referral of a case

I am writing to refer the following case for referral for additional professional
services. The services sought include:

 Medical advice/support  Individual Counselling/therapy
 Couple Counselling/therapy  Child counselling/therapy
 Child Consultation  Other :

This referral is made under the provisions of the Family Law Act (1975), and in

particular I draw your attention to the provisions of Section 10H and Section10J of
the Act, which are included in this referral for your information.

I have permission from the clients to provide the following information:

The clients are attending Family Dispute Resolution with me to resolve issues about their post separation
parenting of their children.
Parent 1. Date of
Full Name Birth

Home Phone Mobile
Address Email
Address

Relationship to the child
Parent 2 Date of
Full Name Birth

Home Phone Mobile
Address Email
Address

Relationship to the child

Please contact me on the number below, to discuss the referral further.

Sincerely

Jon Graham
Family Dispute Resolution Practitioner
Date :_______________________

© Lorri Yasenik and Jon Graham 2016
Private and Confidential
We acknowledge and pay respect to the traditional owners and custodians of the land on which we work and live.
The Institute of Specialist Dispute Resolution Pty Ltd
ABN 46 105 820 791
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