The Women's Centre for Health and Wellbeing

Intake & Referral Form

For Organisations and Individuals

This form is for Organisations to refer a third party to our services.

Individuals can also fill in this form and self refer.
Individuals do not have to fill in this form to get advice or assistance.

This form can be completed at a later date.

If you are not sure what to do, please call us (02) 6021 5773

Women's Centre for Health and Wellbeing Referral Form

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Client Name
DD/MM/YYYY
Gender
Multiple Choice
Do you have a disability?
Do you come from a CALD Background?
CALD means 'culturally and linguistically diverse'
Is an Interpreter needed?

Children and dependants

Do you have children under the age of 18 in your care?
These could be your children, your partners children, you could be an aunt, grandmother, cousin or more
Name of Child 1
DD/MM/YYYY
Name of Child 2
DD/MM/YYYY
Name of Child 3
DD/MM/YYYY
Name of Child 4
DD/MM/YYYY

Other Party or Person of Interest

Name of an Other Party's Details (Person of Interest)
DD/MM/YYYY
Gender
Relationship of POI to the Client
Does the Person of Interest

Referral Services Information

Date / Time
Name of Referrer
DVSAT NSW Completed
MARAM - VIC Adult Child Risk Assessment Tools Completed

Services Required: Please write Yes or No in the space provided

Please write the name/s of the group/s of interest
Has the Client consented to this referral?
Have you completed a reporting guide regarding any child protection concerns?
Does the Client have any specific requirements that need to be addressed?

Risk Identification - Violence towards the client

Have you or your partner seperated in the past 12 months?
Has your relationship ever had money problems?
Has your partner ever threatened to harm or kill you?
Has your partner ever used physical violence against you?
Has your partner ever choked, strangled, or suffocated you or attempted to do these things?
Has your partner ever threatened or assaulted you with any weapon/s? (Knives or Object)
Has your partner ever harmed or killed a family pet or threatened to do so?
Has your partner ever been charged with breaching an apprehended domestic violence order?
Is your partner jealous towards you or controlling of you?
Has the violence or controlling behavior become worse or more frequent?
Has your partner stalked, constantly harassed or text/call/emailed you?
Does your partner control your money?
Does your partner or the relationship have financial difficulties?
Is your partner unemployed?
Does your partner have mental health problems ( either diagnosed or undiagnosed)?
Does your partner have a problem with substance abuse such as alcohol or other substances?
Has your partner ever threatened or attempted suicide?
Is your partner on bail or parole, or served time of imprisonment?
Does your partner have access to firearms or prohibited weapons?

Children

Are you Pregnant?
Has your partner ever harmed or threatened to harm your children?
Are there any Family Court proceedings currently?
Are there children from a previous relationship in the house?
Were the Children present when the incident happened?
Do the children witness family violence often?
Is there a child/children under 1 year?

Sexual Assault

Has your partner ever done things to you of a sexual nature that made you feel bad or physically hurt you?
Has your partner ever been arrested for sexual assault?
Click or drag files to this area to upload. You can upload up to 8 files.

Office Use Only

NSW
VIC