Common Referral Form

Program Program Links for Women Youth Links Child, Youth and Family Services

Program (Please Note: Separate Referral required) Program (Please Note: Separate Referral required) Women's Domestic Violence Court Advocacy Service Find WDVCAS Referral Form here Staying Home Leaving Violence Find SHLV Referral Form here Energy Accounts Payment Assistance Program (EAPA) Find EAPA Referral Form here

When is the Support Needed? When is the Support Needed? Before Court Support At Court Support After Court Support

Please Provide Any Additional Information (Please Note LCN Do Not Provide Mental Health Services, Please Refer to Appropriate Mental Health Agency)

Type of Referral Type of Referral Referral from Government Agency Referral from Community Organisation Self-referral Other / Internal Referral

Date of Initial Referral

Referring Agency / Organisation Name

Agency Worker Name

Agency Worker Phone

Agency Worker Email

Priority Priority Urgent Non urgent

Title / First Name / Last Name

Current Address

Town

Postcode

Phone

Does the Client have an Email Does the Client have an Email Yes No

Email Address

Date of Birth

Preferred Language (if other than English)

Gender Gender Female Male Transgender Non-binary Prefer not to say

Is the Client Culturally and/or Linguistically Diverse? Is the Client Culturally and/or Linguistically Diverse? Yes No

Is an Interpreter Required? Is an Interpreter Required? Yes No

Which Language is the Interpreter Required for?

Is the Client Aboriginal or Torres Strait Islander? Is the Client Aboriginal or Torres Strait Islander? Yes No

Type of Assistance Required Type of Assistance Required Accommodation Support Only

Is the Client/s Homeless? Is the Client/s Homeless? Yes No

Please Provide Further Information

Is the Client/s at Risk of Homelessness? Is the Client/s at Risk of Homelessness? Yes No

Please Provide Further Information

Are You Aware of Any Domestic and Family Violence Issues? Are You Aware of Any Domestic and Family Violence Issues? Yes No

Please Provide Further Information

Are There Any Safety Concerns for the Client? Are There Any Safety Concerns for the Client? Yes No

Please Provide Further Information

Are You Aware of Any Centrelink/Financial Issues? Are You Aware of Any Centrelink/Financial Issues? Yes No

Please Provide Further Information

Is the Client/s Receiving Mental Health or Alcohol and Other Drugs Services? Is the Client/s Receiving Mental Health or Alcohol and Other Drugs Services? Yes No

Please Provide Further Information

Is the Client Engaged with the NDIS? Is the Client Engaged with the NDIS? Yes No

Please Provide Further Information

Are there any Legal Issues or Court Orders Pending? Are there any Legal Issues or Court Orders Pending? Yes No

Please Provide Further Information

Are There any Safety and Risk Issues (WHS) for Workers? Are There any Safety and Risk Issues (WHS) for Workers? Yes No

Please Provide Further Information

Provide Comprehensive Description to Assist Referral

Existing Client of a Service Agency? Existing Client of a Service Agency? Yes No Unsure

What Agency?

Composition of Household (Which of the Following Best Describes the Composition of the Household) Composition of Household (Which of the Following Best Describes the Composition of the Household)Single PersonCouple with DependentsCouple – No DependentsSingle ParentOther

How Many People Currently Live in the Household?

Other – Please Specify

List Dependents Name/s and Date of Birth – if applicable

This confirms that the client/applicant has been read the above privacy statement, indicated that they understand what it means and have given their verbal consent to the above **Consent is valid for one year from date of signing unless otherwise stated This confirms that the client/applicant has been read the above privacy statement, indicated that they understand what it means and have given their verbal consent to the above **Consent is valid for one year from date of signing unless otherwise stated I Consent