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Staying Home Leaving Violence Referral Form

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.


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

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

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

Is it Safe to Call on this Number?


Is the Client Culturally and/or Linguistically Diverse?

Is the Client Engaged With Any Other Multicultural Services?

Is an Interpreter Required?

Is the Client Aboriginal or Torres Strait Islander?

Is the Client Engaged With Any Other Aboriginal or Torres Strait Islander Services?

Type of AVO

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

Risk Posed by Perpetrator

Risk Posed by Client

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