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Home » For Service Providers » SHLV Referral Form

Staying Home Leaving Violence Referral Form

"*" indicates required fields

____

This form is for service providers to refer those who need support with domestic and family violence but wish to remain in their home and have the perpetrator leave. Once you complete the form, an assessment will be conducted to see whether the client fits our criteria.

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 homelessness 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

Location

SHLV Griffith, Leeton, Narrandera, Hay, West Wyalong, Hillston and Lake Cargelligo township

SHLV Wagga Wagga, Junee, Coolamon, Lockhart and surrounding towns

SHLV Cootamundra, Hilltops LGA and Temora

SHLV Gundagai and Snowy Valleys Regional LGA

Initial Referral Information

Date of Initial Referral*

Day

Month

Year

Referring Agency / Organisation Name*

Agency Worker Name*

Agency Worker Phone*

Agency Worker Email*

How long has the Client been with your service?*

Is your service able to provide ongoing case management/support?

Yes

No

What services are you providing to your Client?*

Reason for referral to SHLV?*

Primary Client Details

Client First Name*

First Name Last Name

Current Address

Town*

Postcode*

Is this address the family home, previously shared by the victim and perpetrator?*

Yes

No

Does the client wish to live in her home without the perpetrator of violence?*

Yes

No

Housing Details*

If Other, please provide details

Phone Number

Is it safe to call on this number?*

Yes

No

In No, do you have another number for contact, or a preferred time to contact?

Client email address

Date of Birth

DD slash MM slash YYYY

Country of Birth

Preferred Language (if other than English)

Disability

Yes

No

Details of Disability

Is the Client Culturally and/or Linguistically Diverse?

Yes

No

Please specify Cultural and/or Linguistic information

Is the Client engaged with any other Multicultural service?

Yes

No

What other Multicultural services is the Client engaged with?

Is an Interpreter required?

Yes

No

Which language is the interpreter required for?

Is the client Aboriginal or Torres Strait Islander?

Yes

No

Is the client engaged with any other Aboriginal or Torres Strait Islander services?

Yes

No

What other Aboriginal or Torres Strait Islander services is the Client engaged with?

List Dependants under the care of the Client if applicable (include name/s and date of birth)

Details of other Party (Perpetrator)

Title / First Name / Last Name*

Relationship of Perpetrator to Victim

Current Address

Date of Birth

DD slash MM slash YYYY

Legal Information

Apprehended Violence Orders (including specific clauses)

Type of AVO

Interim

Final

Unknown

Are there any current Family Court orders relating to the children?

Yes

No

Unknown

Please provide details

SHLV Staff Safety

Risk posed by Perpetrator

Moderate

High

Extreme

Please provide details

Risk posed by Client

Unlikely

Moderate

High

Extreme

Please provide details

Consent

Has the Victim consented to the Referral? (If no and you are using professional judgment, please provide our service with any relevant information about the Client’s story to assist with streamlined service delivery and appropriate support the Client may need).

Yes

No

Please provide any extra relevant information

Contact

Phone (office only)

Please see individual programs
for phone numbers.

After Hours

Address (office)

177 Yambil St,
Griffith NSW 2680

Opening Hours

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

Wednesday
1:00pm - 5:00pm

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