Women & Children’s RefugeSelf -ReferralI Need HelpClient Details First Last Date of Birth DD slash MM slash YYYY How do you identify? Male Female Non-binary Agender My gender is not listed I prefer not to answerPreferred personal pronounPhone NumberWhen is the best time to call you?Email address Is it safe for us to email you?(Required) Yes NoWhat is your preferred method of contact?Where are you currently staying? (Please provide the address)Do you receive an income? Yes NoDetails of incomeChildren's details:Please list details of all childrenChild DetailsChilds Name First Last Date of Birth MM slash DD slash YYYY Care ArrangementsAdd anotherRemoveClient background:Were you born in Australia? Yes NoWhat is your cultural background?Do you identify as Aboriginal or Torres Strait Islander? Yes NoDo you need an interpreter? Yes NoRelationships:Relationship status Single Married Separated under one roof Domestic PartnershipAre you currently or have you recently experienced domestic and family violence? Yes NoHow do you rate your current safety? 1 I am safe 2 3 4 5 6 7 8 9 10 Extremely unsafeHas there been any police involvement? Yes NoIs there a current ADVO in place protecting you and/or your children? Yes NoConditions or details of ADVOPersons using violence against youName of person using violence against you First Last Date of Birth MM slash DD slash YYYY Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Relationship to youAdd anotherRemoveServices and Supports:Are their other services helping you out at the moment? Can we talk to them about your situation?ServiceCase WorkerPhone/EmailConsent to discuss Yes NoAdd anotherRemovePlease list the names of other services, case workers and their contact details if it is ok to speak with them.How can Warrina help?Tell us more about how the Women and Children's Refuge and outreach service could help you: Tick all that apply I would like to stay at the Women and Children's Refuge I would like help to relocate out of the area I can't stay living where I am I need help to find somewhere else that is safe and stable to live I would like help creating a safety plan I would like help to engage with a counsellor I would like support to speak to police about the violence I'm experiencing I would like help applying for the Escaping Violence Payment I would like help applying for temporary accomodationRisk Assessment:Are you currently using alcohol or other drugs to cope with your current situation? Yes NoWould you like help from Warrina to manage this? Yes NoIf yes, please provide detailsHave you been diagnosed with a mental health condition? Yes NoDo you think your mental health has been impacted by the domestic violence you are experiencing? Yes NoAre there any other challenges or areas of concern in your life that might be helpful for us to know so we can support you best? Yes NoIf yes, please provide detailsResponse time:Thank you for your referral, we take all referrals seriously and want to respond as best we can according to your needs. It can take up to 2 weeks for us to process referrals.Can you let us know how urgently you need support? I need support right now I can wait up to a week for a response 2 weeks is ok for mePlease contact police on 000 if you're in danger. You can also try calling 1800 RESPECT to speak to a counsellor over the phone immediately or call Link2home on 1800 152 152 for emergency temporary accommodationPlease don't hesitate to contact us directly on 6652 4000 anytime day or night.We hear you please contact police 000 if you’re in danger.You can also try calling 1800 RESPECT (1800 737 732) to speak to a counsellor over the phone immediately or call Link2home on 1800 152 152 for emergency temporary accommodation.PhoneThis field is for validation purposes and should be left unchanged.Δ
