Make a referral to our SHLV Service

Referring Agency

Referral Date

Referrer Name

Phone

Email

Name

DOB

Residential address:

Is this the address previously shared with the perpetrator?
YesNo

Phone

Safe to call & leave voice or text messages?
YesNo

If safe to contact only at set times, please specify:

Email

Safe to email?
YesNo

Country of birth

Year of arrival in Australia

Migrant/VISA status:

Interpreter required
YesNo

Disability/Health/Mental Health issues:
YesNo

If yes, please describe:-

AOD issues:
If yes, please describe:-
YesNo

Household composition (List any other adult members of the household):

Child Name

Age

Date of Birth

In mother’s care
YesNo

Disability, cognition, or impairment
(Inc. mental health) Please specify

Is the person being referred pregnant
YesNo

Are DCJ involved
YesNo

Name

Date of Birth

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

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

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

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.

Please explain the case management supports required: