Home » For Service Providers » WDVCAS Referral Form

WDVCAS Referral Form

The WDVCAS Referral Form is for service providers to refer clients to the Women’s Domestic Violence Court Advocacy Services. 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. 

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.

Type of Referral

WDVCAS Service

SAM Service

Is it Safe to Call on this Number?

Disability

Gender

Is the Client Culturally and/or Linguistically Diverse?

Is the Client Engaged With Any Other Multicultural Services?

Is an Interpreter Required?

Is the Client on a Temporary Visa?

Is the Client Aboriginal or Torres Strait Islander?

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

Gender

Are there any Other Safer Pathways Referrals for this Victim?

Have you Contacted the Police in Relation to this Victim?

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

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

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

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

Does your partner control all the money?

Is your partner unemployed at the moment?

Does your partner have any alcohol or drug problems?

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

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

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

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

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

Has your partner ever threatened to harm or kill you?

Has your partner ever been physically violent toward you?

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

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

Is your partner jealous or controlling?

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

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

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

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

Do you have children / are you pregnant at the moment?

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

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

Are there children from a previous relationship living with you?

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

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

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)