Domestic and Family Violence Redlands Local Link Referral Form
(BP V1.4, May 2023)

•	Please complete this referral form and email any supporting documents to redlandslocallink@centreforwomen.org.au
•	Referrals can also be completed by phone by calling
•	0482 811 980 or
•	0460 626 502

• Medical Objects ID - Centre for Women DFV Local Link: CT4114000YV

Please note that there may be some safety barriers that exist when contacting clients e.g. perpetrator residing in the same household. Please check with the client prior to referring to assist with safe engagement. Thank you.

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Date of Referral: <<Miscellaneous:Date>>

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PATIENT DETAILS

Was the appointment via: <<Telehealth or in person appointment?>>

RE: <<Patient Demographics:Full Name>>
Date of birth: <<Patient Demographics:DOB>>
Gender: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Full Address>>
Phone number: <<Patient Demographics:Phone (Home)>>
Email: <<Patient Demographics:E-mail>>
ATSI: <<Patient Demographics:ATSI>>
Ethnicity: <<Patient Demographics:Ethnicity>>
Language: <<Patient Demographics:Language Spoken>>
Is an interpreter required?: <<Is an interpreter required?>>
Is the person pregnant? <<Is the person pregnant?>>
If pregnant, when is the due date? <<Pregnancy due date>>
Details of any children/dependants of the person being reffered?<<Details of children of person being reffered>>
Do the children/dependants currently live with the person being reffered?<<Do the children live with the person being reffered?>>
Does the perpetrator live in the home?: <<Does the perpetrator live in the home?>>
Is the relevant relationship between the person using violence and your patient: <<relationship between perpetrator and victim>>
List the person using violence's full name if known:<<Person using violence full name >>
If there are multiple people using violence please write their name and relationship below:<<Multiple people using violence? Name, Relationship>>
Is it safe to call?: <<Is it safe to call?>>
Is it safe to text?: <<Is it safe to text?>>
Is it safe to leave voicemail?: <<Is it safe to leave voicemail?>>
 
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DETAILS OF VIOLENCE  

Nature of violence: <<Nature of violence - tick applicable option >>   <<Nature of violence 2 - tick applicable option>>  <<Nature of violence 3 - tick applicable option>>

If there has been physical or sexual violence, has the violence involved?:<<Has physical or sexual violence involved?>> <<Has physical or sexual violence involved 2?>>

Is the client safe right now?: <<Is the client safe right now?>>

Additional comments: <<Additional comments>>

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REFERRING DOCTOR DETAILS

Name: <<Doctor:Name>>
Qualifications: <<Doctor:Qualifications>>
Provider No: <<Doctor:Provider Number>>
Practice Name: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>

Would you like to be notified of the outcome of referral? <<Would you like to be notified of referral outcome?>>
Will you be staying engaged with this client post referral? <<Will you engage with client post referral?>>
Has the client provided consent to share information? <<Has client provided consent to share information?>>

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VERIFICATION

Electronically signed: <<Doctor:Name>>
<<Miscellaneous:Date>>

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----------------------------------------------------------------------------------------------------------------------------------------------------------------RE: <<Patient Demographics:Full Name>>, DOB: <<Patient Demographics:DOB>>
Local Link Referral, MD V1.4 May 2023    Page