DOMESTIC AND FAMILY VIOLENCE REFERRAL FORM

Complete this form, attach relevant documentation and email to IDFVS@catholiccare.org.au

REFERRER DETAILS
Date	Click or tap to enter a date.
Organisation	Click or tap here to enter text.
Referrer Name	Click or tap here to enter text.
Phone number	Click or tap here to enter text.
Email	Click or tap here to enter text.
Role/relationship to client	Click or tap here to enter text.
Option	☐ Staying home Leaving Violence ☐ Renewing Pathways ☐ To be determined

PRIMARY CLIENT DETAILS
Full Name	Click or tap here to enter text.
Other names (maiden, alias, preferred name etc)	Click or tap here to enter text.
DOB	Click or tap to enter a date.
Gender	Click or tap here to enter text.
Address	Click or tap here to enter text.
Phone	Click or tap here to enter text.	Safe to call? ☐ Yes ☐ No Safe to leave voice message? ☐ Yes ☐ No Safe to text message? ☐ Yes ☐ No
Email	Click or tap here to enter text.
Identifies as	Choose an item.
Country of birth	Click or tap here to enter text.
Language spoken at home	Click or tap here to enter text.
Disability/Illness	Click or tap here to enter text.
Currently pregnant?	☐ Yes ☐ No Weeks gestation: Click or tap here to enter text.

DEPENDANTS/ Other Household members (Note: Do not list person causing harm here)
Name	DOB	Gender	Relationship to client	Identifies as	Country of birth	School
Click or tap here to enter text.	Click or tap to enter a date.	Click or tap here to enter text.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.	Click or tap here to enter text.

Note: Please indicate any variations of address and known disability/illness for persons listed here as well as additional person in ‘Other Information’

PERSON CAUSING HARM
Full Name	Click or tap here to enter text.
Other name/s (previous names, maiden, alias)	Click or tap here to enter text.
DOB	Click or tap to enter a date.
Gender	Click or tap here to enter text.
Usual Address	Click or tap here to enter text.
Phone	Click or tap here to enter text.
Email	Click or tap here to enter text.
Identifies as	Choose an item.
Country of birth	Click or tap here to enter text.
Disability/Illness	Click or tap here to enter text.
Currently incarcerated	☐ Yes ☐ No Expected release date: Click or tap to enter a date.
Location	Click or tap here to enter text. MIN:	Click or tap here to enter text.
Known Charges	Click or tap here to enter text.
Is this person currently in a relationship with primary client?	☐ Yes ☐ No

CURRENT HOUSING DETAILS
Type of Housing	Choose an item. If other, please specify: Click or tap here to enter text.
Are the client/safe in their current housing?	☐ Yes ☐ No

OTHER SERVICE INVOLVEMENT
Organisation	Click or tap here to enter text.
Contact Name	Click or tap here to enter text.
Phone	Click or tap here to enter text.
Reason for Engagement	Click or tap here to enter text.
Start Date	Click or tap to enter a date.

OTHER SERVICE INVOLVEMENT
Organisation
Contact Name
Phone
Reason for Engagement
Start Date

COURT MATTERS (Current/Ongoing)
Apprehended Domestic Violence Order (ADVO)	☐ Yes ☐ No ☐ Not known
If yes, what are the conditions?	Click or tap here to enter text.
Expiry Click or tap to enter a date.
Family Law Court (FLC) Orders	☐ Yes ☐ No ☐ Not known
If yes, what are the details:	Click or tap here to enter text.
Children’s Court Orders	☐ Yes ☐ No ☐ Not known
If yes, what are the details:	Click or tap here to enter text.
Other (e.g. Bail conditions or upcoming court dates/matters)	Details:	Click or tap here to enter text.
Additional Information	Click or tap here to enter text.

Note: Please attach copies of any relevant Orders or other documentation to this referral

ADDITIONAL INFORMATION
Has the DVSAT been completed?	☐ Yes ☐ No If yes, please attach to this referral.
Reason for referral	☐ Domestic Violence ☐ Family Violence ☐ Family Law Matters ☐ Domestic Family Violence Education ☐ Victims Services ☐ Safety Planning ☐ ADVO Support
☐ Other, please specify:	Click or tap here to enter text.
Event triggering referral	Click or tap here to enter text.

OTHER INFORMATION
Click or tap here to enter text.

KNOWN RISKS TO WORKERS SAFETY
Click or tap here to enter text.

SIGN OFF
Date	Click or tap to enter a date.
Signature
Referrer Name	Click or tap here to enter text.