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WDVCAS Referral Form

"*" indicates required fields

____

Once submitted, one of our team members will contact you.

Once you complete the form, an assessment will be conducted to see whether the client fits our criteria. Please be aware referrals may take up to three weeks to action due to staff unavailability whilst Family Law Court is sitting.

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

Initial Referral Information

Type of referral: Women’s Domestic Violence Court Advocacy Service (WDVCAS)?

Yes

If Yes for WDVCAS, please select a site from drop down menu

Type of referral: Safety Action Meeting (SAM)? (If Yes is selected, please complete DVSAT section below)

Yes

If Yes for SAM, please select a site from drop down menu

I/we agree to provide additional information regarding to type of referral before submitting this form (add into the DVSAT section at the end of this form)

Yes

Date of Initial Referral*

Day

Month

Year

Referring Agency / Organisation Name*

Agency Worker Name*

Agency Worker Position*

Agency Worker Phone*

Agency Worker Email*

Primary Client Details

Title / First Name / Last Name*

Current Address

Town*

Postcode*

Phone Number

Is it safe to call on this number?

Yes

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

Does the client have an email address?

Yes

If Yes, enter email address

Date of Birth

DD slash MM slash YYYY

Country of birth

Preferred Language (if other than English)

Disability

Yes

If Yes, please specify disability

Gender

Female

Male

Transgender

Non-binary

Is the client Aboriginal or Torres Strait Islander?

Yes

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

Yes

If Yes, what other Aboriginal or Torres Strait Islander Services is the client engaged with?

Is the client Culturally and/or Linguistically Diverse?

Yes

Is the client engaged with any other Multicultural Services?

Yes

If Yes, what other Multicultural Services is the client engaged with?

Is an interpreter required?

Yes

If Yes, which language is the interpreter required for?

Is the client on a temporary Visa?

Yes

If Yes, what type of Visa?

Children

Number of children under 18 years in the care of the client

Child 1

Name

Date of Birth

DD slash MM slash YYYY

Child 2

Name

Date of Birth

DD slash MM slash YYYY

Child 3

Name

Date of Birth

DD slash MM slash YYYY

Child 4

Name

Date of Birth

DD slash MM slash YYYY

Child 5

Name

Date of Birth

DD slash MM slash YYYY

Other Party Details (POI)

Title / First Name / Last Name

Current Address

Town*

Postcode

Date of Birth

DD slash MM slash YYYY

Gender

Female

Male

Transgender

Non-binary

Relationship of POI to Victim

Any current court matters or AVO’s?

Yes

If Yes, please list any relevant information for ADVO or related DFV charges

Background Information

Major risk factors OR reasons for referral

Are there any other safer pathways referrals for this victim?

Yes

Unknown

If Yes, please provide details

Have you contacted the Police in relation to this victim?

Yes

If Yes, please provide details

Have you completed the Mandatory Reporter Guide (MRG) regarding any child protection concerns?

Yes

If Yes, please provide details

Does the victim have any specific requirements that need to be addressed?

Yes

Unknown

If Yes, please provide details

DVSAT Information Part A: Relates to Intimate Relationships only

Have you and your partner separated (in last 12 months)? Are you planning to leave him/her?

Yes

Don't know

Decline to answer

If Yes, please provide details

Has your partner (or the relationship) had money problems?

Yes

Don't know

Decline to answer

If Yes, please provide details

Does your partner control all the money?

Yes

Don't know

Decline to answer

If Yes, please provide details

Is your partner unemployed at the moment?

Yes

Don't know

Decline to answer

If Yes, please provide details

Does your partner have any alcohol or drug problems?

Yes

Don't know

Decline to answer

If Yes, please provide details

Does your partner have any mental health problems or do you have any concerns about his/her mental health?

Yes

Don't know

Decline to answer

If Yes, please provide details

Has your partner ever threatened or tried to kill him/herself?

Yes

Don't know

Decline to answer

If Yes, please provide details

Is your partner on bail/parole or ever been to jail?

Yes

Don't know

Decline to answer

If Yes, please provide details of any violent offences that they have been convicted of

Does your partner have access to guns or other weapons?

Yes

Don't know

Decline to answer

If Yes, please provide details

Has your partner ever threatened or assaulted you with any weapon (knives/objects)?

Yes

Don't know

Decline to answer

If Yes, please provide details

Has your partner ever strangled, choked or suffocated you or tried to do so?

Yes

Don't know

Decline to answer

If Yes, please provide details

Has your partner ever threatened to harm or kill you?

Yes

Don't know

Decline to answer

If Yes, please provide details

Has your partner ever been physically violent toward you?

Yes

Don't know

Decline to answer

If Yes, please provide details

Do you have any pets? Has your partner ever threatened to harm or kill your pets or actually done so?

Yes

Don't know

Decline to answer

If Yes, please provide details

Has your partner stalked or harassed you or constantly texted or emailed you?

Yes

Don't know

Decline to answer

If Yes, please provide details

Is your partner jealous or controlling?

Yes

Don't know

Decline to answer

If Yes, please provide details

Is the violence or controlling behaviour getting worse or happening more often?

Yes

Don't know

Decline to answer

If Yes, please provide details

Has your partner ever hurt you sexually or made you do things that you didn’t want to do?

Yes

Don't know

Decline to answer

If Yes, please provide details

Do you know if your partner has ever been arrested for sexual assault?

Yes

Don't know

Decline to answer

If Yes, please provide details

Do you know if your partner has ever been charged with breaching an AVO?

Yes

Don't know

Decline to answer

If Yes, please provide details

Do you have children?

Yes

Don't know

Decline to answer

If Yes, please provide details (How old are they? Less than 12 months apart?)

Are you pregnant at the moment?

Yes

Don't know

Decline to answer

Has your partner ever threatened to or actually physically hurt you while you were pregnant?

Yes

Don't know

Decline to answer

If Yes, please provide details

Has your partner ever threatened to harm your children or actually done so?

Yes

Don't know

Decline to answer

If Yes, please provide details

Are there children from a previous relationship living with you?

Yes

Don't know

Decline to answer

If Yes, please provide details

Are there family court or child contact or residency proceedings at the moment?

Yes

Don't know

Decline to answer

If Yes, please provide details and if has there been conflict about this

DVSAT Information Part B: Professional Judgement

How fearful is the client of their partner? (Select one answer)

What concerns did the client express? What did the client think their partner might do and to whom?

Are you aware of any other additional factors, circumstances or details which make you believe overall there is a threat or serious threat to the safety of the client and/or children?

Were there children present or witness to the incident?

Have you done the Mandatory Reporter Guide? What was the result? Have you followed the Mandatory Reporter Guide direction?

Consent

Has the victim consented to the referral?

Yes

(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)

Any extra relevant information

Upload any additional attachments if required

Drop files here or

Accepted file types: docx, pdf, jpg, png, Max. file size: 64 MB.

Date

MM slash DD slash YYYY