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Common Referral Form

Please note: If you require these specific services, please access their dedicated referral forms:

• Women’s Domestic Violence Court Advocacy Service Click to access WDVCAS Referral Form

• Staying Home Leaving Violence Click to access SHLV Referral Form

• Energy Accounts Payment Assistance Program (EAPA) Click to access EAPA Referral Form

• Family Advocacy and Support Services (FASS) Click to access FASS Client Intake Form

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"*" indicates required fields

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Once submitted an assessment will be undertaken to see whether the client meets our criteria and if so someone will attempt contact with the client within 72 hours.

Privacy Statement

Linking Communities Network Ltd collects your personal information in order to provide assistance, support and advocacy to clients. This information will provide important statistics and help us find the most suitable service to suit your needs. Your personal information is protected under law and will not be passed on to anyone without your consent.

Question for client
Do you provide consent for your personal information (name, sex, date of birth and suburb), the date you applied for assistance and the name of this service; to be available to other government and non-government support services in NSW for one year after today’s date? Your personal information will be managed in accordance with the Information Privacy Act 2009.

Consent*

Yes, I provide consent

Program Referring to within LCN – please note LCN do not provide mental health services, please refer to appropriate mental health agency

Select a program (see above for other services and related Referral Form links)*

Links for Women

Youthlinks

Targeted Early Intervention (Child, Youth and Family Services)

Male referral over 25 years

Domestic, Family and Sexual Violence Program - Hay/Carrathool LGA

Domestic, Family and Sexual Violence Program - Cootamundra/Gundagai LGA

Domestic, Family and Sexual Violence Program - Temora LGA

Domestic, Family and Sexual Violence Program - Leeton and Narrandera LGA

Why are you referring to LCN – what needs does the client identify? Please provide background information and any other relevant information that will assist the assessment and eligibility process for our programs.*

Initial Referral Information

Date of Referral*

Day

Month

Year

Type of referral*

Referral from Government Agency

Referral from Community Organisation

Other/Internal Referral

Self referral

Referring Agency

Agency Worker Name

Agency Worker Phone

Agency Worker Email

Primary Client Details

Title / First Name / Last Name*

Current Address*

Town*

Postcode*

Phone Number*

Does the client have an email address?*

Yes

If Yes, enter email address

Date of Birth*

DD slash MM slash YYYY

Preferred Language (if other than English)

Gender*

Female

Male

Transgender

Non-binary

Name

Date of Birth

DD slash MM slash YYYY

Gender

Female

Male

Transgender

Non-binary

Prefer not to say

Cultural Identity

Are there additional Children?

Yes

If Yes, please enter additional children's details

Composition of Household – which of the following best describes the composition of the household?*

Assistance Required

Is the client currently homeless?*

Yes

If Yes, please provide further information

Is the client at risk of homelessness?*

Yes

Why is the client at risk of homelessness? How much longer can they currently stay where they are?

Are you aware of any domestic and family violence issues?*

Yes

If Yes, please provide further information including any AVO and perpetrator information where applicable

Are there any safety concerns for the client and/or children?*

Yes

If Yes, what are the safety concerns for the client/s and/or children?

Are you aware of any Centrelink/financial issues?*

Yes

If Yes, please provide further information

Does the client have identification?*

Yes

If Yes, what type of identification does the client have?

Is the client/s receiving mental health or alcohol and other drugs services?*

Yes

If Yes, please list mental health provider/s and any further relevant information

Is the client engaged with the NDIS?*

Yes

If Yes, please list NDIS provider and any further relevant information

Are there any legal issues or court orders pending?*

Yes

If Yes, what are the legal issues? List dates of court if known and any other relevant information

Are there any safety and risk issues (WHS) for workers?*

Yes

If yes, please list risks for workers

Existing client of a service agency?*

Yes

If yes, select relevant service agencies

Please select all that apply

Mental Health service

Child Protection service

Homelessness service

Domestic Violence service

Disability service

Out of Home Care service

Youth service

Family Preservation service

Other

If you have selected 'Other', please provide details

Consent

I consent to the disclosure of my personal information to other state or commonwealth government agencies and /or non government community agencies in order that community recovery services can be provided to address my identified needs. This confirms that the client/applicant has been read the above privacy statement, indicated that they understand what it means and have given their consent to the above **Consent is valid for one year from the date of signing unless otherwise stated.*

I consent

Contact

Phone (office only)

(02) 6964 4804

Please see individual programs
for phone numbers.

Enquire Here

After Hours

1800 650 051

Address (office)

177 Yambil St,
Griffith NSW 2680

Opening Hours

Monday, Tuesday, Thursday, Friday
9:00am - 5:00pm

Wednesday
1:00pm - 5:00pm