{"id":26,"date":"2023-03-06T00:20:17","date_gmt":"2023-03-06T00:20:17","guid":{"rendered":"https:\/\/stoic-stonebraker.202-74-66-189.plesk.page\/?page_id=26"},"modified":"2023-03-06T00:20:21","modified_gmt":"2023-03-06T00:20:21","slug":"lilly-pilly-intake-form","status":"publish","type":"page","link":"https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/lilly-pilly-intake-form\/","title":{"rendered":"LILLY PILLY INTAKE FORM"},"content":{"rendered":"\n<div class=\"wp-block-contact-form-7-contact-form-selector\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f28-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/26#wpcf7-f28-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"28\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.8.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f28-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<h4>PERSONAL INFORMATION\n<\/h4>\n<p><b>Information provided in this form is treated as CONFIDENTIAL<\/b>\n<\/p>\n<p>Please select option:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"status\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"status\" value=\"Person being supervised\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Person being supervised<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"status\" value=\"Person with whom child\/ren reside\" \/><span class=\"wpcf7-list-item-label\">Person with whom child\/ren reside<\/span><\/span><\/span><\/span><br \/>\n<label> Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"family-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"family-name\" \/><\/span> <\/label><br \/>\n<label> Address:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"family-addy\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"family-addy\" \/><\/span> <\/label><br \/>\n<label> Mobile:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"family-number\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"family-number\" \/><\/span> <\/label><br \/>\n<label> Email Address:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"family-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"family-email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Emergency contact name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency-contact-name\" \/><\/span> <\/label><br \/>\n<label> Emergency contact number:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency-contact-number\" \/><\/span> <\/label>\n<\/p>\n<p><label> Legal representative's name \/ firm \/ self rep:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"legal-rep-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"legal-rep-name\" \/><\/span> <\/label><br \/>\n<label> Legal representative Phone number:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"legal-rep-number\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"legal-rep-number\" \/><\/span> <\/label><br \/>\n<label> Legal representative Email:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"legal-rep-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"legal-rep-email\" \/><\/span> <\/label>\n<\/p>\n<h4>CHILD\/REN DETAILS\n<\/h4>\n<p><label> Number of child\/ren to be supervised:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"children-count\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"children-count\" \/><\/span> <\/label><br \/>\n<label> Relationship to person being supervised:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"relationship\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"relationship\" \/><\/span> <\/label><br \/>\n<label> How long since child\/ren have seen or spoken with the Supervised Parent:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-seen\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-seen\" \/><\/span> <\/label>\n<\/p>\n<p><b>CHILD 1<\/b><br \/>\n<label> Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-one-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-one-name\" \/><\/span> <\/label><br \/>\n<label> Gender:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-one-gender\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-one-gender\" \/><\/span> <\/label><br \/>\n<label> DOB:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-one-dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"child-one-dob\" \/><\/span> <\/label><br \/>\n<label> Age:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-one-age\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-one-age\" \/><\/span> <\/label><br \/>\nVaccinations up to date:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-one-vaccinations\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"child-one-vaccinations\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"child-one-vaccinations\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span><br \/>\n<label> Legal representative (ICL):<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-one-icl\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-one-icl\" \/><\/span> <\/label>\n<\/p>\n<p><b>CHILD 2<\/b><br \/>\n<label> Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-two-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-two-name\" \/><\/span> <\/label><br \/>\n<label> Gender:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-two-gender\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-two-gender\" \/><\/span> <\/label><br \/>\n<label> DOB:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-two-dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"child-two-dob\" \/><\/span> <\/label><br \/>\n<label> Age:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-two-age\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-two-age\" \/><\/span> <\/label><br \/>\nVaccinations up to date:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-two-vaccinations\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"child-two-vaccinations\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"child-two-vaccinations\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span><br \/>\n<label> Legal representative (ICL):<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-two-icl\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-two-icl\" \/><\/span> <\/label>\n<\/p>\n<p><b>CHILD 3<\/b><br \/>\n<label> Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-three-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-three-name\" \/><\/span> <\/label><br \/>\n<label> Gender:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-three-gender\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-three-gender\" \/><\/span> <\/label><br \/>\n<label> DOB:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-three-dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"child-three-dob\" \/><\/span> <\/label><br \/>\n<label> Age:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-three-age\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-three-age\" \/><\/span> <\/label><br \/>\nVaccinations up to date:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-three-vaccinations\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"child-three-vaccinations\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"child-three-vaccinations\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span><br \/>\n<label> Legal representative (ICL):<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"child-three-icl\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-three-icl\" \/><\/span> <\/label>\n<\/p>\n<p><label> Behavioural notes\/concerns (ICL):<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"behaviour\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"behaviour\"><\/textarea><\/span> <\/label><br \/>\n<label> Medical information (e.g. allergies):<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medical\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"medical\"><\/textarea><\/span> <\/label>\n<\/p>\n<h4>REQUESTED VISIT DETAILS\n<\/h4>\n<p><label> Starting date:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"start\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"start\" \/><\/span> <\/label><br \/>\n<label> List all dates OR Specify frequency (i.e. weekly, fortnightly):<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"frequency\" \/><\/span> <\/label><br \/>\n<label> Finish date OR blank if ongoing:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"finish\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"finish\" \/><\/span> <\/label><br \/>\n<label> Visits start and finish time (excluding transport):<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"time\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"time\" \/><\/span> <\/label><br \/>\nTransport to and from venue required?:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"transport\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"transport\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"transport\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span><br \/>\n<label> Transport additional details:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"transport-info\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"transport-info\" \/><\/span> <\/label><br \/>\n<label> Contact venue\/s :<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"venue\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"venue\" \/><\/span> <\/label><br \/>\n<label> Attendees (List all attendees):<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"attendees\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"attendees\" \/><\/span> <\/label><br \/>\nDomestic Violence Orders:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dom-order\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"dom-order\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"dom-order\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span><br \/>\nIf \"yes\" please attach file:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"domestic-order\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"domestic-order\" \/><\/span><br \/>\nFamily \/ Federal CC Orders?:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fam-order\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"fam-order\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"fam-order\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span><br \/>\nIf \"yes\" please attach file:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"family-order\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"family-order\" \/><\/span><br \/>\nParenting Plan (signed by both parties)?:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fam-plan\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"fam-plan\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"fam-plan\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span><br \/>\nIf \"yes\" please attach file:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"family-plan\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"family-plan\" \/><\/span>\n<\/p>\n<p>Are you responsible for payment of the service:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"payment-plan\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"payment-plan\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"payment-plan\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span><br \/>\n<label> If \"yes\" please percentage (or dollar amount) of responsibility:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"payment\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payment\" \/><\/span> <\/label><br \/>\n<label> Additional information that may assist the supervisor :<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"additional-info\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"additional-info\"><\/textarea><\/span> <\/label><br \/>\n<b>ALL COSTS ARE PAYABLE BEFORE SCHEDULED SUPERVISED CONTACT OR OTHER SERVICES<\/b>\n<\/p>\n<h4>SERVICE AGREEMENT\n<\/h4>\n<p><b>All service users must complete and sign this form<\/b>\n<\/p>\n<p>This Agreement is a contract between you and Lilly Pilly. The information and terms in this document apply to your use<br \/>\nof our services. In signing this document you agree that you will be bound by the terms and conditions in this<br \/>\nAgreement. If you do not want to be bound by this Agreement, you must stop using our Services.<br \/>\nWe may amend this Agreement at any time, for example if we update the operation of our Services or as required by<br \/>\nlaw. All future changes included in a policy update are incorporated by reference into this agreement.<br \/>\nIf we make significant changes to this Agreement which may impact on your use of our services or our service provision,<br \/>\nwe will email you an updated copy of the Lilly Pilly Service Agreement for your records.<br \/>\nAny changes to the Lilly Pilly Service Agreement will take effect 30 days after the updated Agreement has been<br \/>\nprovided.\n<\/p>\n<p>By continuing to use our Services after any amendments to this Agreement, you agree to abide and be bound by any<br \/>\nchanges. If you do not agree with any changes we make to this Agreement, you may terminate this Agreement by<br \/>\nterminating use of this service.\n<\/p>\n<p>I agree to the following:\n<\/p>\n<p>1. I understand that all court order directions shall be strictly adhered.<br \/>\n2. I have read and agree to the Lilly Pilly terms and conditions for service use outlined in the Lilly Pilly Service<br \/>\nAgreement.<br \/>\n3. I agree that the information provided in this form is correct and any changes\/ additional dates will need to be<br \/>\napproved by both parties and sent in writing to Lilly Pilly.<br \/>\n4. I agree that changes to this Intake Form without prior approval from the other party may incur an<br \/>\nadministration fee, invoiced to the person responsible for attempted changes.<br \/>\n5. I understand whilst at Lilly Pilly I may be under video and sound recording.<br \/>\n6. I acknowledge that this information provided to Lilly Pilly does not hold privilege in court, and that Lilly Pilly<br \/>\nmay in certain limited circumstances be required, whether by law, court order or government authority,<br \/>\ndisclose parts of, or all, information held in your file.<br \/>\n7. I understand there may be other children and adults at the centre during the period of visits.\n<\/p>\n<p><b>CONDUCT<\/b>\n<\/p>\n<p>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<br \/>\nunderstand it is my responsibility to inform the other party through relevant legal channels. I am aware that a<br \/>\nlate cancellation fee will be incurred if I cancel after 5pm of the weekday before my contact visit.<br \/>\n2. I will comply with the agreed arrangements.<br \/>\n3. I will comply with the reasonable directions of the Contact Supervisor.<br \/>\n4. I will not come to the contact visit under the influence of drugs or alcohol, nor partake in the consumption of<br \/>\ndrugs or alcohol during the contact.<br \/>\n5. I will not be aggressive or abusive towards Lilly Pilly personnel prior to, during or after the contact visit.<br \/>\n6. If I feel that I am getting distressed or upset at any point during the contact visit, I will step away to collect<br \/>\nmyself.<br \/>\n7. I am aware that my contact visit can be cancelled if I do not abide by any of the above points.<br \/>\n8. In relation to any additional attendees, I will advise Lilly Pilly in advance of the contact visit. Any attendees<br \/>\nNOT approved to attend must be listed on the Referral Form following agreement from both parties.\n<\/p>\n<p><b>CLIENT DISCLAIMER<\/b>\n<\/p>\n<p>1. I agree that the information provided to Lilly Pilly is true and correct to the best of my knowledge and belief.<br \/>\n2. I agree, as a condition of participating in any activity supervised by Lilly Pilly and its Contact Supervisors, I<br \/>\nrelease and indemnify Lilly Pilly from and against any liability arising directly or indirectly out of such<br \/>\nparticipation (including negligence).<br \/>\n3. To the fullest extent permitted by law, the Indemnity covers, but is not limited to, any liability arising out of,<br \/>\nor as a direct or indirect consequence of any harm, loss, damage, bodily injury or death sustained<br \/>\nby myself, my child\/ren and any attendees as a result of participation in the activities (including transportation<br \/>\nof children\/attendees to and from such activities), or being present at a premises utilised by Lilly Pilly for the<br \/>\npurpose of Contact Supervisory services or handovers.\n<\/p>\n<p><a href='https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/lilly-pilly-intake-service-agreement\/'>Click here to read Lilly Pillys Intake & service agreement<\/a>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-898\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"checkbox-898[]\" value=\"I have read Lilly Pillys Intake &amp; service agreement\" \/><span class=\"wpcf7-list-item-label\">I have read Lilly Pillys Intake &amp; service agreement<\/span><\/span><\/span><\/span><br \/>\n<label> Print Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sig-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"sig-name\" \/><\/span> <\/label><br \/>\n<label> Date:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sig-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"2026-05-01\" type=\"date\" name=\"sig-date\" \/><\/span> <\/label><br \/>\nSignature:<br \/>\n<span class=\"wpcf7-form-control-wrap wpcf7-sign-wrap sig\"><input class=\"wpcf7-form-control wpcf7-sign wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"sig\" type=\"hidden\" \/>\n            <canvas style=\"display:block\" data-hidden=\"sig\" class=\"signature-pad\" width=400 height=200><\/canvas>\n            <button class=\"btn btn-primary cf7sg-sign\">Clear<\/button>\n        <\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><p style=\"display: none !important;\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"78\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_uag_custom_page_level_css":"","site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-26","page","type-page","status-publish","hentry"],"uagb_featured_image_src":{"full":false,"thumbnail":false,"medium":false,"medium_large":false,"large":false,"1536x1536":false,"2048x2048":false,"mailpoet_newsletter_max":false},"uagb_author_info":{"display_name":"admin","author_link":"https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/author\/notifications_hwyhfwn6\/"},"uagb_comment_info":0,"uagb_excerpt":null,"_links":{"self":[{"href":"https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/wp-json\/wp\/v2\/pages\/26","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/wp-json\/wp\/v2\/comments?post=26"}],"version-history":[{"count":3,"href":"https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/wp-json\/wp\/v2\/pages\/26\/revisions"}],"predecessor-version":[{"id":1812,"href":"https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/wp-json\/wp\/v2\/pages\/26\/revisions\/1812"}],"wp:attachment":[{"href":"https:\/\/nervous-cohen.202-74-66-189.plesk.page\/index.php\/wp-json\/wp\/v2\/media?parent=26"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}