Leaving Violence Program Online Referral Form

Leaving Violence Program Referral Form

the Leaving Violence Program Referral form gathers essential information to assess eligibility.

Referrer details

Name

Phone

Organisation

Relationship to client

Type of support provided

Length of time supporting the client

Eligibility checklist

Client must meet all criteria – please check before making a referral

Are 18 years and over

Has not accessed the national Escaping Violence Payment in the last 12 months – please let the client know that NAAFLS will need to call Telstra Health as the national provider to check

Lives in Darwin, Palmerston, Big Rivers, Top End, West Daly, East Arnhem, West Arnhem, or Tiwi Islands

Is currently experiencing or has experienced intimate partner violence

Has changed living arrangements in the last 12 weeks due to the violence, or is planning to change living arrangements due to the violence

Has money worries (is experiencing financial stress)

Agrees to work with a support organisation to develop a safety and support plan

I confirm I have read and understand the Leaving Violence Program eligibility and I have confirmed the client is eligible before referring

Signature

Clear

Client details

1. I confirm the information I have provided is true and correct

2. I consent for my information and documentation to be provided to NAAFLS to support my referral to the Leaving Violence Program

3. I consent to NAAFLS providing my name, date of birth and address to Telstra Health to check if I have accessed the payment in the last 12 months

Are you comfortable being supported by a male worker?

Yes

Don't mind

Signature

Clear

Client name

Date of birth

Languages spoken

Interpreter needed

Yes

Client Phone

Is it safe to call, text or leave a message on this phone?

Yes

Alternative contact number

Who will answer?

Is it safe to leave a message or send a text?

Yes

Client address

Name(s) of children or dependents

Their dates of birth

Languages spoken

Interpreter needed

Yes

Key cultural information including: skin name / Aboriginal name, community / homeland / outstation of origin (where the client was brought up or where their family is from - mother, father, grandparent’s Country)

Short story of relationship:

Short story of intimate partner violence:

Supporting document:

Professional judgement

Full name of person using violence:

Date of birth

Skin name / Aboriginal name of person using violence

Address of person using violence

Current and proposed client living arrangement, such as: Has the client moved? Did the client’s partner leave? If client is planning to leave, where are they going?

Short story of client’s money worries:

What help does the client require from NAAFLS? For example, does the client require financial assistance only? Or financial assistance and case management support?

What is the client’s biggest worry, and what support is needed first?

If you are human, leave this field blank.

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Leaving Violence Program Referral Form and DFSV Safety Planning

Before completing this form

How to refer

Leaving Violence Program Referral Form

Referrer details

Eligibility checklist

Client details