Domestic and Family Violence Brisbane Local Link Referral Form

(MD V1.5, April 2025)

Complete this form and email supporting documents to PHNLocalLink@Micahprojects.org.au
Referrals can also be completed by phone by calling 07 3013 6035 
Medical Objects ID for Micah Projects Local Link:DB41010005B

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Date of Referral: <<Miscellaneous:Date>>

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PATIENT DETAILS

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?>>
Note: Please check with client about safest way to engage with them if there are concerns of stalking, monitoring or escalation of violence if services are engaged. 
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?>>
Are there any important aspects of your patient's identity or orientation that we should know about to better support them?: <<Important details re identity or orientation?>> 
Does your patient have any access or support needs?: <<Any access or support needs?>>

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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 any of the following risk factors?:<<Has physical or sexual violence been involved?>> <<Has physical or sexual violence been involved 2?>>

Is the client currently safe?: <<Is the client currently safe?>>

Has the violence been reported to the police? <<Has violence been reported to police?>>

Perpetrator relationship to client? <<Perpetrator relationship to client>>

Is there current contact between the parties? <<Current contact between the parties?>>

Does the perpetrator live with the client?: <<Does the perpetrator live with the client?>>

Further details and risks: <<Further details and risks>> 
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PLEASE COMPLETE IF CLIENT IS 17 YEARS OLD or YOUNGER

Safe parent/guardian name: <<Safe parent/guardian name>>
Safe parent/guardian DOB: <<Safe parent/guardian DOB>>
Safe parent/guardian gender: <<Safe parent/guardian gender>>
Relationship to client: <<Relationship to client>> 
Phone: <<Phone>>
Email: <<Email>>

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MANDATORY REPORTING

Under Queensland Government legislation, it is an offence for any adult to believe a child has been or is being sexually abused and not report this to the police or Child Safety.
Have you reported to police?: <<Have you reported this to police?>>
Have you reported to Child Safety?: <<Have you reported to Child Safety?>>
Is there ongoing or historic Child Safety involvement? <<Ongoing or historic Child Safety involvement?>>
Are there any other services involved for the client?: <<Any other services involved for the client?>>
Further details and risks: <<Further details and risks>>

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REFERRING DOCTOR DETAILS

Name: <<Doctor:Name>>
Practice Name: <<Practice:Name>>
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 for this referral? <<Has client provided consent for this referral?>>
Are there ongoing medical or health concerns that impact the vulnerability of this client? If yes, please provide details: <<Ongoing medical or health concerns.>>

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VERIFICATION

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

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Local Link is part of Brisbane South PHN's Recognise, Respond, Refer (RRR) Program, which supports primary care to enhance service responses to people experiencing DFV, SV and CSA. This service is supported by funding from the Australian Government through Brisbane South PHN.