Referral Form Is this a self referral or agency referral? Self ReferralAgency Referral Please be aware that due to current high demand there is a longer than usual wait time for an initial appointment with our Victim Support Unit. We will contact your referred client to book an appointment at the first available opportunity. Please be aware that due to current high demand there is a longer than usual wait time for an initial appointment with our Victim Support Unit. We will contact you to book an appointment at the first available opportunity. For emergencies and urgent needs please contact: 000 Lifeline 13 11 14 1800RESPECT (1800 737 732) 13YARN (13 92 76) Did the crime occur within NSW? YesNo Please note at this point in time we are only able to support victims of crime which occurred within NSW. Victim-Survivor Details Name Preferred Name Phone Number Email Date of Birth Address Gender Please SelectFemaleMaleNon-BinaryPrefer not to say Aboriginal or Torres Strait Islander? Please SelectYesNo Culturally and linguistically diverse (CALD) ? Please selectYesNo Is there a disability? Please selectYesNo Agency Referral Details: Referrer's Name Referrer's Organisation Referrer's Phone Number Referrer's Email Support Required Victims Services CounsellingVictims Services Financial AssistanceAssistance with police statementCourt preparation and supportVictim Impact StatementFamily Court matterState Parole Authority SubmissionCoroners Court matterMental Health Review TribunalOther Crime Type Abduction/detained without consentArsonBreak and EnterCriminal Road AccidentFamily ViolenceFraudHome InvasionHomicideGlassingPhysical AssaultSexual Violence - recentSexual Violence - historicalStabbingShootingTheft/RobberyThreats, stalking, intimidation,Technology facilitated abuseOther Perpetrator's Name The Perpetrator's Relationship to victim-survivor Date or time frame in which the crime occurred Police Event Number Police Station Please SelectNewcastleWaratahBelmontTorontoRaymond TerraceMaitlandCessnockOther Please provide details of any AVO conditions and/or Criminal Charges How did you hear about VOCAL? Please provide as much detail as possible about the incident/situation. Please provide as much detail as possible about the incident/situation. Please upload any supporting documentation (limit of 10mb) Send copy of referral submission to this email address (required) We will confirm with you via email upon acceptance of the referral.
