Staying Home Leaving Violence Referral Form

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

Date of Initial Referral

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? 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?

Title / First Name / Last Name

Current Address

Town

Postcode

Is this address the family home, previously shared by the victim and perpetrator? 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? Does the client wish to live in her home without the perpetrator of violence? Yes No

Housing Details Housing DetailsOwn Home/ MortgagePrivate RentalSocial HousingOther

Provide Details

Phone

Is it Safe to Call on this Number? Is it Safe to Call on this Number? Yes No

If No, Do You Have Another Number for Contact or a Preferred Time to Contact?

Client Email Address

Date of Birth

Country of Birth

Preferred Language (if other than English)

Disability Disability Yes No

Details of Disability

Is the Client Culturally and/or Linguistically Diverse? 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 Services? Is the Client Engaged With Any Other Multicultural Services? Yes No

What Other Multicultural Services is the Client Engaged With?

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

Is the Client Engaged With Any Other Aboriginal or Torres Strait Islander Services? 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 Dependents Under The Care of the Client if Applicable (Name/s and Date of Birth)

Title / First Name / Last Name

Current Address

Date of Birth

Relationship of Perpetrator to Victim

Apprehended Violence Orders (including specific clauses)

Type of AVO Type of AVO Interim Final Unknown

Are there any current Family Court orders relating to the children? Are there any current Family Court orders relating to the children? Yes No Unknown

Please Provide Details

Risk Posed by Perpetrator Risk Posed by Perpetrator Moderate High Extreme

Please Provide Details

Risk Posed by Client Risk Posed by Client Unlikely Moderate High Extreme

Please Provide Details

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) 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) Yes No

Please Provide Any Extra Relevant Information