MOBILE DOMESTIC VIOLENCE SERVICE Ph: 08 9021 2836 | Mob: 0400 926 429 Email: carla@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
Organisation
Contact Number
Email

CLIENT DETAILS
Please note: Only women with or without children experiencing Family & Domestic Violence in the Goldfields region are eligible for a referral.
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

SUPPORT SERVICES
Tick services required	Risk Assessment	Safety Planning	FVRO / VRO Application	Court Support
Legal	Counselling	Housing	Mental Health
Connection to Country	Financial	Advocacy	Children Support
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.
BRIEF DESCRIPTION OF CLIENT MATTERS

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