DOMESTIC VIOLENCE OUTREACH Ph: 08 9021 2836 | Mob: 0428 027 993 Email: DV-Outreach@finlaysonhouse.com.au PO Box 666, Kalgoorlie WA 6433

REFERRAL FORM

Acknowledgement to County

Our service would like to acknowledge the traditional custodians of the land on which we stand, and we pay our respects to the elders’ past, present and emerging.

REFERRER DETAILS
Name	Position
Organisation
Contact Number
Email

VICTIM DETAILS
Please note: Only women who are 18+ years old, with or without children experiencing AT RISK or HIGH RISK Family & Domestic Violence in the Goldfields region are eligible for a referral. To ensure the Risk Assessment is demonstrated, a Common Risk Assessment must be completed in conjunction with this referral. Although not essential, it is desirable to also have a Personal Safety Plan completed and attached to this referral if possible.
Name
Surname
Phone	Date of Birth
Address
Aboriginal / Torre Strait Islander	Aboriginal	Torres Strait Islander	Both	Neither

CHILDREN’S DETAILS
Name	Date of Birth	Gender

PERPETRATOR DETAILS
Name
Surname
Date of Birth	Gender
Address
Aboriginal / Torre Strait Islander	Aboriginal	Torres Strait Islander	Both	Other (please specify)

RISK ASSESSMENT DETAILS
ALL referrals to our service must include a completed Risk Assessment, (Preferably using the Common Risk Assessment tool found in the Common Risk Assessment Management Framework.).
A formal Risk Assessment has been conducted and is attached to this referral.	Yes	No
Referrer’s Assessment of Risk (in accordance to the Common Risk Assessment result)	Low Risk	At Risk	High Risk
SUPPORT SERVICES
Tick services required	Emergency Accommodation	Emergency Relief	FVRO / VRO Application	Court Support
Advocacy	Alcohol & Drugs	Child/ren Support	Counselling
Disability	Employment / Training	Financial	Health
Housing	Legal	Mental Health	Sexual Assault
Does this client have a Family Violence Restraining Order (FVRO or VRO) in place?	Interim Order	Final Order	Conduct Order
Does this client have housing?	Private	Department of Housing	Short-term Placement
Other (Please provide details)
DEPARTMENT OF COMMUNITIES
Does this client currently have an open case with the Department of Communities – Child Protection & Family Services?	Yes	No	Closed
Case Worker Name
Case Worker District
If the client has indicated YES or CLOSED in the above, then please advise client that our service may need to contact the Case Worker for a discussion or additional information if appropriate or relevant, so written consent is required from client as part of this referral.
BRIEF DESCRIPTION OF CLIENT MATTERS
ACTIONS ALREADY TAKEN BY REFERRER

OUR CORE VALUES

RESPECT

Respecting the choices that people make regardless of personal thoughts and opinions

JUSTICE

Encouraging fairness without discrimination and advocating on behalf of those who are unable to advocate for themselves

HOPE

To work on healing the body, mind and soul. Work towards the transformation of a better existence

COMPASSION

Engage with those in need, to alleviate one’s suffering and no longer stand alone

SUPPORT

Work together to meet desires to transform lives of the individual and/or children