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

•	Please complete this referral form and email any supporting documents to locallink@yfs.org.au
•	Referrals can also be completed by phone by calling
•	07 3826 1500

• Medical Objects ID for YFS Beaudesert DFV Local Link: KK4280000PA

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: <TodaysDate>

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PATIENT DETAILS
Was the appointment via: <In person or telehealth appoinment>
RE: <PtFullName>
Date of birth: <PtDoB> 
Gender: <PtSex> 
Address: <PtAddress>
Phone number: <PtPhoneH>
Email: <PtEmail>
Aboriginal or Torres Strait Islander origin: <Aboriginal or Torres Strait Islander>
Ethnicity: <PtEthnicity>
Language spoken: <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/dependents of the person being reffered? <Details of dependents/children (Name, DOB, Gender)>
Do the children/dependents currently live with the person being reffered? <Is the childrens/dependent currently living 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: <Is the relevant relationship between the person using violence and your patient>
List the person using violence's full name if known: <Person using violence's full name>
If there are multiple people using violence please write their name and relationship below:<If there are multiple people using violence write their name and relationship below>
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 a voicemail?: <Is it safe to leave a voicemail?>

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DETAILS OF VIOLENCE  

Nature of violence: <Nature of violence - select all that apply>		
 
If there has been physical or sexual violence, has the violence involved?: <If there has been violence, has it involved (select all that apply)>

Is the client safe right now?: <Is the client safe right now?>
 
Additonal comments: <Additional comments>
 
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PERPERTRATORS DETAILS 

Perpetrator Name: <Perpetrator's Name> 
Perpetrator DOB: <Perpetrator's DOB>

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REFERRING DOCTOR DETAILS

Name: <DrDetails>
Qualifications: <DrQualifications>
Provider No: <DrProviderNo>
Practice Name:<Practice>
Address: <UsrAddress>
Phone: <DrPhone>
Fax: <DrFax>

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

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VERIFICATION

Electronically Signed: <DrDetails>
<TodaysDate>

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RE: <PtFullName> DOB: <PtDoB>
Local Link Referral Form, BP V1.4, May 2023      Page