WDVCAS Referral Form

Type of Referral Type of Referral Women’s Domestic Violence Court Advocacy Service Safety Action Meeting - Domestic Violence Safety Assessment Tool (DVSAT)/ risk identification tool to be completed at bottom of referral

WDVCAS Service WDVCAS Service Murrumbidgee WDVCAS Riverina WDVCAS Murray River WDVCAS

SAM Service SAM Service Murrumbidgee WDVCAS Riverina WDVCAS Murray River WDVCAS

Date of Initial Referral

Referring Agency / Organisation Name

Agency Worker Name

Agency Worker Position

Agency Worker Phone

Agency Worker Email

Title / First Name / Last Name

Current Address

Town

Postcode

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?

Does the Client have an Email Does the Client have an Email Yes No

Email Address

Date of Birth

Country of Birth

Preferred Language (if other than English)

Disability Disability Yes No

Details of Disability

Gender Gender Female Male Transgender Non-binary

Is the Client Culturally and/or Linguistically Diverse? Is the Client Culturally and/or Linguistically Diverse? Yes No

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 on a Temporary Visa? Is the Client on a Temporary Visa? Yes No

If Yes, What Type of Visa?

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

Gender Gender Female Male Transgender Non-binary

Relationship of POI to Victim Relationship of POI to VictimPartnerEx-partnerCarerChildAdult ChildSiblingParentGrandparentGrandchildOther RelationSharing a HouseSharing a Residential FacilityStalkerAssociate of Partner or Ex-partner

Background Information / Major Risk Factors OR Reasons for Referral

Are there any Other Safer Pathways Referrals for this Victim? Are there any Other Safer Pathways Referrals for this Victim? Yes No Unknown

Please Provide Details

Have you Contacted the Police in Relation to this Victim? Have you Contacted the Police in Relation to this Victim? Yes No

Please Provide Details

Have you completed the Mandatory Reporter Guide (MRG) regarding any child protection concerns? Have you completed the Mandatory Reporter Guide (MRG) regarding any child protection concerns? Yes No

Please Provide Details

Does the victim have any specific requirements that need to be addressed? Does the victim have any specific requirements that need to be addressed? Yes No Unknown

Please Provide Details

Have you and your partner separated (in last 12 months)? Are you planning to leave him/her? Have you and your partner separated (in last 12 months)? Are you planning to leave him/her? Yes No Did not answer

Please Provide Details

Has your partner (or the relationship) had money problems? Has your partner (or the relationship) had money problems? Yes No Did not answer

Please Provide Details

Does your partner control all the money? Does your partner control all the money? Yes No Did not answer

Please Provide Details

Is your partner unemployed at the moment? Is your partner unemployed at the moment? Yes No Did not answer

Please Provide Details

Does your partner have any alcohol or drug problems? Does your partner have any alcohol or drug problems? Yes No Did not answer

Please Provide Details

Does your partner have any mental health problems or do you have any concerns about his/her mental health? Does your partner have any mental health problems or do you have any concerns about his/her mental health? Yes No Did not answer

Please Provide Details

Has your partner ever threatened or tried to kill him/herself? Has your partner ever threatened or tried to kill him/herself? Yes No Did not answer

Please Provide Details

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 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 Yes No Did not answer

Please Provide Details

Does your partner have access to guns or other weapons? Does your partner have access to guns or other weapons? Yes No Did not answer

Please Provide Details

Has your partner ever threatened or assaulted you with any weapon (knives/objects)? Has your partner ever threatened or assaulted you with any weapon (knives/objects)? Yes No Did not answer

Please Provide Details

Has your partner ever strangled, choked or suffocated you or tried to do so? Has your partner ever strangled, choked or suffocated you or tried to do so? Yes No Did not answer

Please Provide Details

Has your partner ever threatened to harm or kill you? Has your partner ever threatened to harm or kill you? Yes No Did not answer

Please Provide Details

Has your partner ever been physically violent toward you? Has your partner ever been physically violent toward you? Yes No Did not answer

Please Provide Details

Do you have any pets? Has your partner ever threatened to harm or kill your pets or actually done so? Do you have any pets? Has your partner ever threatened to harm or kill your pets or actually done so? Yes No Did not answer

Please Provide Details

Has your partner stalked or harassed you or constantly texted or emailed you? Has your partner stalked or harassed you or constantly texted or emailed you? Yes No Did not answer

Please Provide Details

Is your partner jealous or controlling? Is your partner jealous or controlling? Yes No Did not answer

Please Provide Details

Is the violence or controlling behaviour getting worse or happening more often? Is the violence or controlling behaviour getting worse or happening more often? Yes No Did not answer

Please Provide Details

Has your partner ever hurt you sexually or made you do things that you didn’t want to do? Has your partner ever hurt you sexually or made you do things that you didn’t want to do? Yes No Did not answer

Please Provide Details

Do you know if your partner has ever been arrested for sexual assault? Do you know if your partner has ever been arrested for sexual assault? Yes No Did not answer

Please Provide Details

Do you know if your partner has ever been charged with breaching an AVO? Do you know if your partner has ever been charged with breaching an AVO? Yes No Did not answer

Please Provide Details

Do you have children / are you pregnant at the moment? Do you have children / are you pregnant at the moment? Yes No Did not answer

Please Provide Details (How old are they? Less than 12 months apart?)

Has your partner ever threatened to or actually physically hurt you while you were pregnant? Has your partner ever threatened to or actually physically hurt you while you were pregnant? Yes No Did not answer

Please Provide Details

Has your partner ever threatened to harm your children or actually done so? Has your partner ever threatened to harm your children or actually done so? Yes No Did not answer

Please Provide Details

Are there children from a previous relationship living with you? Are there children from a previous relationship living with you? Yes No Did not answer

Please Provide Details

Are there family court or child contact or residency proceedings at the moment? Are there family court or child contact or residency proceedings at the moment? Yes No Did not answer

Please Provide Details (if yes, has there been conflict about this?)

How fearful is the client of their partner? Select one answer. How fearful is the client of their partner? Select one answer. Not Afraid Afraid Terrified Unable/ Unwilling to 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?

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