• Referral Consent and Purpose

  • Reason for Referral
  • What date did you obtain consent from the client to refer them to our service?*
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  • By submitting this form, my client consents to The Centre for Women & Co., / Men & Co. Services collecting, using and sorting their personal information to establish a client file and respond to your inquiry.  We will contact the client using their preferred communication methods in relation to your request. Their information will be managed confidentially in accordance with the Information Privacy Act 2009 (Qld) and the Queensland Privacy Principles (QPPs).  Your client retains the right to: Withdraw consent at any time, Access or correct personal information we hold about them, Lodge feedback, compliments or complaints. For more details on how we manage client information please view our Policy Page.
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  • Client Details

  • Format: (000) 000-0000.
  • Is it safe to call you?*
  • Is it safe to text you?*
  • Is it safe to email you?*
  • Is it safe to leave you a voicemail identifying ourselves?*

  • Children's Details

  • Do you want your client's Intake Worker at CFW to discuss the options for Child & Youth DFV Counselling with the client for their child or children?

  • Person Using Violence Details

  • Support Needs

  • Referrer Details

  • Will you be continuing to support this client?
  • Do you need a referral outcome for this client?*

  • Documentation

  • If you have any relevant documentation (such as Domestic Violence Orders) you would like to submit, please do so here.

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