For More Information Phone: (08) 9395 9488
Juvenile and Family Fire Awareness Program
AGENCY REFERRAL
Name of referring person: / Agency:
Email address: / Phone number:
CHILD DETAILS
Name: / Gender:
Date of birth: / Age: / Ethnicity:
School: / Year at School:
Home address:
Parent / Carer Email Address:
Is an interpreter required? / Yes / ☐ / No / ☐ / Not known / ☐
If yes, language spoken?
Does the child have a learning/behavioural disorder? / Yes / ☐ / No / ☐ / Not known / ☐
If yes, please specify: / Conduct disorder (CD)* / ☐
Oppositional defiant disorder (ODD)* / ☐
Attention Deficit Disorder (ADD)* / ☐
Attention Deficit Hyperactivity Disorder (ADHD)* / ☐
Autism Spectrum Disorder / ☐
Asperger’s Syndrome / ☐
Deaf or Hearing Impairment / ☐
Learning Disability / ☐
Other (please specify):
*Is the child medicated? / Yes / ☐ / No / ☐ / Not known / ☐
FAMILY DETAILS
Primary care giver 1
Name: / Phone number:
Relationship to child: / Mother ☐ Father ☐ Other (please specify):
Primary care giver 2
Name: / Phone number:
Relationship to child: / Mother ☐ Father ☐ Other (please specify):
Marital status: / Single ☐ Married/De facto ☐ Separated/Divorced ☐
Number of siblings: / Birth order:
Any current stress in the family?
e.g. death of family member, health issues, recent divorce or separation, change of schools, peer issues, etc
FIRE LIGHTING DETAILS
Date of most recent fire lighting incident:
Detailed description of most recent fire lighting incident (including a description of child’s involvement in the fire lighting incident, the methods used and the extent of damage):
As a result of the fire lighting incident:
☐ Fire brigade attended
☐ Police attended – if Yes, ☐ Caution ☐ Referred to JJT ☐ Court summons
☐ Ambulance attended
☐ There was parental or adult intervention
☐ Other (please specify):
Please provide any additional information that may assist the JAFFA Support Officer:
Is the parent/carer supportive of the young person’s involvement in the JAFFA Program? / Yes / ☐ / No / ☐
Is the parent/carer aware that their child’s involvement in JAFFA is voluntary? / Yes / ☐ / No / ☐
Would the young person’s home be a suitable location for the delivery of the education session(s)?
(JAFFA is usually delivered in the family home. It helps us to know if the home is a safe place, free of many distractions). / Yes / ☐ / No / ☐ / Not known / ☐
Including the current fire lighting incident, how many times has the young person played with fire, including matches or lighters, or set something on fire?
Please return the completed form to:
For more information phone: (08) 9395 9488
September 2016