Referral Intake Form

Referral Intake Form

Please complete the following form for all referrals.
Daytime Referrals - Call (08) 8970 2221
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Referrer Information
Full Name*

First NameLast Name
Role/Position*
Organisation (eg/ Clinic, Police, School)*
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Contact Email
example@example.com
Client Details
Client Full Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Usual Address and other Locations
Child/rens Names & DOB
Accessibility requirements (Wheelchair, Hard of Hearing)
Does the client need to see medical staff?

YesNoUnsure
Mental Health, Addiction, Suicide or Self Harm

Diagnosed Mental Health ConditionPrevious History of Suicidal ideationCurrent addiction impacting behaviourPrevious History of Self HarmClient has been seen by GP or Mental Health Expert and confirmed they are not a danger to themselves or others
Current Medications, Medical Needs, Mental Health Concerns or further details regarding risks identified above
Person Using Violence (PUV)
Person Using Violence

First NameLast Name
Date of Birth

MonthDayYear
Date
Usual Address and Current Location
PUV - Risks and Safety Alerts

Police are aware of this caseCurrent DVOPUV is in Custody
Violence Story
Recent Incident details - and why current situation is causing immediate danger or concerns for DFSV behaviours escalating
Please include types of violence, patterns of behaviour, Injuries - Current or Historical, DVO - Current, Expired or previous? Any family orders?
Mandatory Reporting

Reported to PoliceReported to Dept Children & FamiliesNot Reported to PoliceNot Reported to Dept Children & Families
Risk Assessment

Person Using Violence

Rows	Previous History	Current Condition/ Situation	Possible immediate risk	No immediate risk
Uses violence on other people
Has weapons
Has threated to kill client
Has threated to kill or harm children
Uses controlling behaviour
History of stalking
Breached DVO before
Recent release from prision
Does PUV drink grog, kava, smoke ganja or use other drugs
Keeps client from leaving the house
History of DFSV

Is there anything else that you think we should know? or do you have more information to add regarding risks identified?
Referral Type

What type of referral are you making.
Crisis Stay – Up to two weeks
There has been a recent incident of DFSV, and these is an immediate risk of danger. They do not have a safe accommodation option.

Prevention Stay – Up to Two Nights Available Monday to Wednesday Only
The person has identified early warning signs that behaviour may escalate into DFSV and requires safe accommodation and support to develop a safety plan aimed at reducing risk and preventing further escalation.

On Going Support and Wellbeing Services
Client is not in immediate risk of danger but will benefit from supported activities, wellbeing, education or a safe place to rest.
What type of service is being requested for the individual?*

Crisis Stay - Up To Two WeeksPrevention Stay - Escalating violence - Stays up to 2 nights Monday to WednesdayOutreach and Drop-in Service - Available Thursday and Friday during Business hours
Crisis Stay Details - Up to 2 weeks - Immediate Risk clients only
Who is eligible for a Crisis Accommodation Stay?
- Clients identifying as women from 18 years of age unless accompanied by an adult
- Accompanying minors - Boys up to age 10
- Client who meet the high-risk criteria
Clients must be experiencing Domestic, Family or Sexual Violence and meet the following high risk criteria below:
- Person has experienced serious physical injuries
- Client has a Police reported DFSV case or Domestic Violence Order
- Client meets Mandatory reporting criteria (meaning Risk Assessment is High)
- There is no other family support and nowhere safe to stay
- A child has witnessed DFSV, or we believe a child is being or has been harmed or abused
WE ARE NOT A RESPITE CENTRE, MENTAL HEALTH SERVICE OR HOMELESS SHELTER

Low risk sistuations that client does not meet criteria for Crisis or Prevention Stay may include things like:
- Humbug / arguments over food, drugs, domestic duties
- Family disagreements
- Non- life threatening DFSV Behaviour
Brief reason for crisis stay referral
Prevention Stay Details - Up to 2 nights - Available Mon to Wed Only

Prevention Stays can be offered for clients that are experiencing escalating risks of violence - Referrals during Business Hours only.
Brief reason for prevention stay referral
Outreach and Drop-in Service Details

Galiwin'ku Women's Space can provide Wellbeing programs including Art Therapy, Counselling, Cultural activities such as hunting trips, etc.
Brief reason for drop-in service referral
Drop in Service Interests

WellbeingHunting TripsArt TherapyCounsellingOther
Signature
Should be Empty:

Rows	Previous History	Current Condition/ Situation	Possible immediate risk	No immediate risk
Physically Assaulted
Pregnant (Risk is high if so)
PUV has or tried to strangle/choak client
PUV has used weapons on client
Separation has been discussed or in process
Client is suicidal
Client is Self-Harming
PUV has forced to have sex with client
Client Identifies as LGBTQI
Children have witnessed DFSV

Referral Intake Form

Daytime Referrals - Call (08) 8970 2221

Referrer Information

Client Details

Person Using Violence (PUV)

Violence Story

Risk Assessment

Referral Type

Crisis Stay Details - Up to 2 weeks - Immediate Risk clients only

Prevention Stay Details - Up to 2 nights - Available Mon to Wed Only

Outreach and Drop-in Service Details