Men & Co. Services
Referral Form
Does the client consent to this referral to Men & Co. Services. If 'no' please obtain consent from the client before proceeding with this referral.
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Yes
No
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.
My client consents to the collection, use, and storage of their personal information as outlined in the Privacy Notice and Consent Notice above.
My client does not consent to this.
Notice about Referral Processing and Managing Referral Demand. Due to high demand, Pathways to Change has limited intake capacity. Submission of a referral does not guarantee immediate acceptance into the program. Referrals will be reviewed in accordance with current group availability and service capacity. If we cannot ensure a client can be accepted into our program within a reasonable timeframe, we may close the referral and provide alternate support pathways. Clients are always able to re-refer, however, we do not maintain a waitlist as we cannot provide meaningful risk management and support during this time. For our Statewide program, priority catchment referrals will be prioritised over non-priority catchment referrals. In the Redlands program, time of referral and suitability for behaviour change group work will inform prioritisation of incoming referral demand.
I understand
I do not understand - please reach out to us to discuss this further before proceeding on 07 3439 8640
What is your name?
What is your work email?
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example@example.com
What organisation are you from?
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Do you require an outcome from this referral?
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Yes
No
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Client Details
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the client identify as
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander
Culturally and Linguistically Diverse
None of the above
What is the client's preferred language? If not English, do they want an interpreter?
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Support Needs
What program/s is the client interested in?
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Redlands Pathways to Change - Men's Behaviour Change Program 17+ (16 Weeks)
Queensland Pathways to Change - Men's Behaviour Change Program 17+ (16 Weeks)
Are any of the below in effect?
Domestic Violence Order
Family Court Orders
Parenting Plan
Other Orders or Plans
Are any other agencies involved with this client? If yes, please name.
Please provide any relevant information in regards to your ongoing support with this client (if any).
Please provide any relevant information in regards to the client's situation, use of violence or abuse, family functioning and motivation to engage with Men & Co. Services.
Are there any risk factors or intersectionalities you feel are relevant for Men & Co. Services to know when working with this client to promote victim-survivor safety and empowerment?
Please upload any files you feel are relevant such as DVOs and Family Court Orders.
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