DFV Disability Focus Casework Service Referral Form

Servicing Greater Sydney

Please contact DFV Disability Focused team for clarification on referral eligibility if required.

Eligibility Criteria – MANDATORY QUESTIONS

Did the client consent to the referral?
YesNo

(If no, referral cannot be accepted)

Is there a current ADVO
YesNo

If yes, please provide a copy

NB: If the client is not willing to pursue an ADVO please explain why in the ‘Reason for referral’ field

DVSAT

Score

please provide a copy

Serious Threat
YesNo
(If yes, referral to local SAM must have been made)

Referred to SAM
Yes - Date:Location:No

Referred by

Referring Agency

Referral Date

Referrer Name

Phone

Client details

Other details

Perpetrator Details

Name

Date of Birth

Gender Identity

Relationship to Client

ATSI
YesNo

Is this Person known by any other name
YesNo
If yes, please describe:-

Current location/address (eg.residential/custody)

Upcoming court matters (local, family, criminal and civil)

Presenting issues E.G. mental health, AOD

Warnings/ safety concerns E.G. access to weapons, wanted by Police, OMCG member

Additional Information

Does the client have any concern for their safety and the children’s safety
YesNoNot Stated
If yes, please describe:-

Does the person being referred want to remain in their home
YesNo

OTHER SUPPORTS

Are there any other services or agencies involved with the client?
Please specify:

Reason for referral / background of DV history

PLEASE NOTE: If not enough information is provided, the referral may be considered ineligible. This will also avoid the client from having to retell their story. Please include all known current risks and support needs.

Identified needs:

Explain the case management supports/goals identified/required by the client (Note: don’t exceed 400 word count)

Please fill in the online form and submit when completed. Please note that the online form needs to be completed in one session otherwise your information may time out.
OR
Please click below to download a fillable version of the form to complete and return to dfvdisability@jsc.org.au when possible. Download form

DFV Disability Focus Casework Service Referral Form

Servicing Greater Sydney

Eligibility Criteria – MANDATORY QUESTIONS

Referred by

Client details

Other details

Perpetrator Details

Additional Information

OTHER SUPPORTS

Reason for referral / background of DV history

Identified needs:

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