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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
Please enable JavaScript in your browser to complete this form.
Date
Client Name
First
Last
Client Maiden Name/Alias
Date of Birth
*
DD/MM/YYYY
Gender
Woman
Trans
Girl
Non-Binary
Client Phone Number
Client Address
Multiple Choice
Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander
Not Applicable
Do you have a disability?
Yes
No
Do you come from a CALD Background?
Yes
No
Prefer not to say
CALD means 'culturally and linguistically diverse'
Is an Interpreter needed?
Yes
No
What Language do we need an interpreter for?
Children and dependants
Do you have children under the age of 18 in your care?
Yes
No
I'm not sure
These could be your children, your partners children, you could be an aunt, grandmother, cousin or more
If you have Children, what is the number of children under 18 yrs in your care, or how many children are in the care of the client
Name of Child 1
First
Last
Date of Birth Child 1
DD/MM/YYYY
Relationship to Child 1
Relationship to Person of Interest (POI)
Name of Child 2
First
Last
Date of Birth Child 2
DD/MM/YYYY
Relationship to Child 2
Relationship to Person of Interest (POI)
Name of Child 3
First
Last
Date of Birth Child 3
DD/MM/YYYY
Relationship to Child 3
Relationship to Person of Interest (POI)
Name of Child 4
First
Last
Date of Birth Child 4
DD/MM/YYYY
Relationship to Child 4
Relationship to Person of Interest (POI)
If you have more children, please list their first and last name, date of birth and relationship to you
Relationship of these children to the Person of Interest (POI)
Other Party or Person of Interest
Name of an Other Party's Details (Person of Interest)
First
Last
Maiden Name or different name the POI is known by
Date of Birth
DD/MM/YYYY
Gender
Woman
Man
Trans
Identify as Non-Binary
Relationship of POI to the Client
Partner
Ex -Partner
Carer
Child
Adult Child
Sibling
Grandparent
Grandchild
Other Relationship
Does the Person of Interest
Own a house with you?
Share accommodation with you?
Is it a Stalker?
Is it the associate of a partner or an ex partner?
Other
Referral Services Information
Date / Time
Date
Time
Name of Referrer
*
First
Last
Name of Agency
Email
*
Best Contact Phone Number
DVSAT NSW Completed
YES - Attach a copy via the form portal below
NO - Please complete the RISK Identification below
MARAM - VIC Adult Child Risk Assessment Tools Completed
YES - Please attach/upload copies
NO - Please complete the RISK Identification below
Services Required: Please write Yes or No in the space provided
Counseling
Domestic Violence
Sexual Assault
Housing
Financial
Hume Riverina Legal Services Clinic
Victims of Crime Application
Counselling
Work Development Order NSW or VIC
Our Sisters Closet
NILS No Interest Loans
Crisis Support Package
Food Voucher
Staying Home Leaving Violence Support
Therapeutic Groups - Shark Care, Circle of Parenting Support, Self Esteem, Knotts
Please write the name/s of the group/s of interest
Wellbeing Groups - Meditation, Anxiety
Justice of the Peace Service
AVO Application Assistance
External Service Referrals
Other
Has the Client consented to this referral?
Yes
No
Have you completed a reporting guide regarding any child protection concerns?
Yes
No
Does the Client have any specific requirements that need to be addressed?
Yes
No
Unknown
Please use the space provided for additional information
Risk Identification - Violence towards the client
Have you or your partner seperated in the past 12 months?
Yes
No
I am planning to leave them
Unknown
Refused Answer
Has your relationship ever had money problems?
Yes
No
Unknown
Refused Answer
Has your partner ever threatened to harm or kill you?
Yes
No
Unknown
Refused Answer
Has your partner ever used physical violence against you?
Yes
No
Unknown
Refused Answer
Has your partner ever choked, strangled, or suffocated you or attempted to do these things?
Yes
No
Unknown
Refused Answer
Has your partner ever threatened or assaulted you with any weapon/s? (Knives or Object)
Yes
No
Unknown
Refused Answer
Has your partner ever harmed or killed a family pet or threatened to do so?
Yes
No
Unknown
Refused Answer
Has your partner ever been charged with breaching an apprehended domestic violence order?
Yes
No
Unknown
Refused Answer
Is your partner jealous towards you or controlling of you?
Yes
No
Unknown
Refused Answer
Has the violence or controlling behavior become worse or more frequent?
Yes
No
Unknown
Refused Answer
Has your partner stalked, constantly harassed or text/call/emailed you?
Yes
No
Unknown
Refused Answer
Does your partner control your money?
Yes
No
Unknown
Refused Answer
Background of the Partner
Does your partner or the relationship have financial difficulties?
Yes
No
Unknown
Refused Answer
Is your partner unemployed?
Yes
No
Unknown
Refused Answer
Does your partner have mental health problems ( either diagnosed or undiagnosed)?
Yes
No
Unknown
Refused Answer
Does your partner have a problem with substance abuse such as alcohol or other substances?
Yes
No
Unknown
Refused Answer
Has your partner ever threatened or attempted suicide?
Yes
No
Unknown
Refused Answer
Is your partner on bail or parole, or served time of imprisonment?
Yes
No
Unknown
Refused Answer
Does your partner have access to firearms or prohibited weapons?
Yes
No
Unknown
Refused Answer
Children
Are you Pregnant?
Yes
No
Unknown
Refused Answer
Has your partner ever harmed or threatened to harm your children?
Yes
No
Unknown
Refused Answer
Are there any Family Court proceedings currently?
Yes
No
Unknown
Refused Answer
Are there children from a previous relationship in the house?
Yes
No
Unknown
Refused Answer
Were the Children present when the incident happened?
Yes
No
Unknown
Refused Answer
Do the children witness family violence often?
Yes
No
Unknown
Refused Answer
Is there a child/children under 1 year?
Yes
No
Unknown
Refused Answer
Sexual Assault
Has your partner ever done things to you of a sexual nature that made you feel bad or physically hurt you?
Yes
No
Unknown
Refused Answer
Has your partner ever been arrested for sexual assault?
Yes
No
Unknown
Refused Answer
Would you like to disclose any other information?
You may not need to upload any documents - this portal is available if needed.
Click or drag files to this area to upload.
You can upload up to 8 files.
Office Use Only
NSW
1 or more YES = Threat
12 or more YES = Serious Threat SAMS Referral Required
VIC
1 or more YES = AT RISK
12 or more - ELEVATED RISK
Client is at serious risk - refer to RAMP
Client at immediate risk are requires protection - referral VIC Police, RAMP, CAV
Office Notes
Phone
Submit Form
