Referral forms

Please contact CASACV on 5441 0430 if you have any queries regarding the completion of the referral form.

If you run out of time to complete the form, use the "Save Form and Complete Later" link at the bottom to generate a unique link that you can email to yourself to return and then complete it.

Referrer details

Referral date*

Name of referrer*

Organisation*

Phone*

Fax

Email*

Referral counselling

Client details

Child's Name*

Date of birth*

Gender*

Aboriginal / Torres Strait Islander*

Country of birth

Language spoken

Phone number

Address

please include town or suburb

Household members

Name	Relationship to child

Please indicate if the child shares a room with any household members

Caregiver details

Parents / Guardians

Carer's name

Parent / guardian phone

Carer's address (if different from above)

Interpreter required

No
Yes

Language Spoken (if an interpreter is required)

Referral details

Type of sexual assault*

Current
Historical

please check all that apply

When did the sexual assault occur?*

Recently – within the last month
Not as recently – within the last 6 months
A little while ago – between 6 months to 2 years ago
In the past – over 2 years ago

Details of historic assault

Perpetrator status*

relative
known person
unknown person
multiple perpetrators

Multiple perpetrators*

relative
known person
unknown person

please check all that apply

Has the person experienced Family Violence (current or past experience)?*

Details of family violence.*

Has abuse been substantiated?*

Yes
No

Agency substantiating

e.g. police or C.P.

Alleged nature of abuse?*

How often and over what period of time?

When was the last known episode of abuse?*

Please provide details.

Recent SOCIT or police involvement?*

Yes
No

SOCIT or police involvement details*

Recent DHHS involvement?*

Yes
No

DHHS Involvement details*

Has DHHS had prior involvement with this family?*

Yes
No

Previous DHHS involvement details*

Current protective factors

Have all mandatory reporting requirements been met (i.e. Crimes Amendment (Protection of Children) Act 2014)?*

Yes
No

Does the child have any trauma history (ie emotional, psychological, physical or sexual)?*

Yes
No

Trauma details*

Is a genogram available?*

Yes
No

Genogram*

Max. file size: 300 MB.

please attach a copy, if available

Reasons genogram not developed / supplied*

Hidden

Has the child been exposed to any family violence (ie emotional, psychological, physical or sexual)?*

Yes
No

Has a safety plan been developed?*

Yes
No

Safety plan*

Max. file size: 300 MB.

please attach a copy.

Reasons safety plan not developed / supplied*

Family’s response to / support for the referral*

Will DHHS continue to work with the family?*

Yes
No

Future DHHS Involvement

Are there current orders in place through childrens or family court?*

Yes
No

Court orders details

Are the following available to assist our assessment?

Court report
DHHS case planning minutes
Other professional assessments

Attach any supporting documents you have to hand now.

Drop files here or

Max. file size: 300 MB.

What are the main concerns you would like addressed with the child through counselling?

Other agencies involved with the client / family

Agency	Contact person	Phone / email

Other relevant information

Additional comments

Is it OK for CASACV to identify themselves while leaving a message for the client on their phone?*

Yes
No

Self referral

Your details

Sexual assault details

Referral (adult)

Referrer details

Client details

Referral details

Referral (children & adolescents)

Referrer details

Client details

Caregiver details

Referral details

Referral (DFFH child protection)

Referrer details

Client details

Referral details

Referral - REFOCUS

Referrer details

Client details

Caregiver details

Referral details

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