Women’s Domestic Violence Court Advocacy Service (WDVCAS) ReferralStep 1 of 520%Client DetailsClient name First Last Date of birth DD slash MM slash YYYY Gender Female Male Non-binary Agender My gender is not listed Prefer not to answerAddress Street Address Address Line 2 Suburb Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Post Code Contact numberDoes the client have a disability? Yes No UnknownDoes the client identify as LGBTIQ? Yes No UnknownDoes the client identify as Aboriginal or Torres Strait Islander? No Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander UnknownDoes the client identify as from a CALD background? Yes No UnknownDoes the client require an interpreter to communicate? Yes NoIf Yes, type of interpreterName and age of children (If Applicable)Perpetrator DetailsNameRelationship to ClientDate of Birth (Note: must be at least 10 years or older) DD slash MM slash YYYY Gender Female Male Non-binary Agender My gender is not listed Prefer not to answerAddress of the person being referred? Street Address Address Line 2 Suburb Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Post Code Why are you referring this client to WDVCAS? Specialist domestic and family violence support (e.g. referrals, safety planning, infomation or help at court) and/or Safety Action MettingNOTE: If you are referring the client so they can be discussed at a SAM, this means you think the client is at serious threat of injury or death due to domestic and family violence. Please explain why you think the client is at serious threat. If you have completed a DVSAT or other risk assessment, please send it toPlease explain why you think the client is at serious threat.If you have completed a DVSAT or other risk assessment, please send it toHas the client consented to this referral being made? Yes NoDo not proceed with the referral unless you believe the client is at serious threat and you are making the referral so that the client can be listed on a SAM agendaIf no, does the client know that you are making this referral? Yes NoOther detailsHave you made any other referrals for the client? (For example, housing, financial support, medical care, mental health support etc.) Yes NoIf yes, please provide details (for example, date, service referred to, reason for the referral and outcome if known).Do you have any child protection concerns? Yes NoIf yes, please provide details including information about any reports that have been made and email any relevant documentationReferrer detailsName First Last PositionService/OrganisationEmail Phone NumberDate of referral MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.Δ
