Emergency Accommodation Request for Staff Form (QLD)

Request date/time - no need to fill out this section it's automatic

DateHourMinutesAM/PM Option

Thank you for your request to engage with ProCare to support the Young Person in Emergency Accommodation.

We understand that these situations are highly stressful and time sensitive. In order to streamline the process we will require the following information to assist you with your request and to finalise a booking.

We are requesting the following information so we are able to get an idea of what the support involves so we can allocate the most appropriate Youth Worker, and ensure they are equipped with all the relevant information so that they are able to successfully complete the support and provide the appropriate support to the Young Person, while ensuring the safety of both Youth Worker and Young Person.

Please answer all of the following to the best of your ability; we understand due to the circumstances you may not be able to provide all of this information now, however we will require answers to all of the below to be able to finalise the booking. You can use these questions as a guide to identify what needs to be approved.

Young Person's Name

Young Person's Date of Birth*

Date

Young Person's Cultural Identity*

Behaviours/Triggers/Safety Concerns*

Any medication required?*

Does the Young Person have a Diagnosis or a Suspected Diagnosis?:*

Dates of Support

Accommodation Name and Address (eg: Quest Eight Mile Plains and address)*

Accommodation Booking Name and Confirmation Number*

(if you have an itinerary from the accommodation, please attach)

Food (How will our Youth Worker be feeding the Young Person?) *

Eg: Food Vouchers, Reimbursements of Purchases, Online Shopping Orders and How much $ will be allowed?)

Activities (Free Activity Suggestions, Paid Reimbursements with a Cost Limit)

Eg: What the Young Person likes to do

Mandatory Appointments / Court Dates (Time and Location):*

Are over night shifts required to be Sleepovers or Awake?:*

Sleep Over shifts OnlyAwake shifts onlyCombination of Sleep Over and Awake shifts

Is a Male or Female or Either Gendered Youth Worker Required?*

Male PreferredFemale PreferredNo Preference

Does the assigned ProCare Australia worker require an NDIS Check Clearance to fulfill this shift?*

YesNo

Are there any other Child Safety Officers/Child Safety Service Centres or key stakeholders involved? (Names, Positions, Emails, Contact Numbers)*

Is there a Safety Plan in place? (If so, please attach)*

Click Here to Upload Safety Plan

Emergency Contact Information*

Is there anything else that the Youth Worker needs to know when completing the support for this Young Person?

Risks, Past Behaviour, Triggers, De-escalation Strategies, legal obligations etc

I appreciate your assistance with providing all the relevant information so that we can provide support to the Young Person.

If you have any questions, Please let me know via return email, or you can call our office on 07 3708 2833.

*ALL EMERGENCY ACCOMMODATIONS MUST BE APPROVED AND FINALSIED BEFORE 4:15PM OR PROCARE AUSTRALIA IS UNABLE TO ASSIST.

Approving Managers Name*

First NameLast Name

Approving Managers Contact Number

Area CodePhone Number

Approving Managers Email*

example@example.com