Referral Form Is this a self referral or agency referral? Self ReferralAgency Referral Victim-Survivor Details 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 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 Police Event Number Police Station Please SelectNewcastleWaratahBelmontTorontoRaymond TerraceMaitlandCessnockOther Please provide details of any AVO conditions and/or Criminal Charges Please provide as much detail as possible about the incident/situation. We will confirm with you via email upon acceptance of the referral.
