Local Link Referral Form Logan and the Redlands
(BP V2.1, July 2025)

Please complete this referral form and email it and any supporting documents to redlandslocallink@centreforwomen.org.au or loganlocallink@centreforwomen.org.au 
Referrals can also be completed by phone by calling 0482 811 980 or 0460 626 502 or faxing 07 3144 5602.
Medical Objects ID for the Centre of Women & Co Local Link: CT4114000YV.

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Date of Referral: <TodaysDate>

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CLIENT DETAILS (please note if client is under 18 years old complete additional information on page 2)

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>

Are there any important aspects of your patient's identity or orientation that we should know about to better support them? <Any identity or orientation information we should know>

Does your patient have any access or support needs?: <Access or support needs>
 
Note: Please check with the client about the safest way to engage with them if there are concerns about 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 a voicemail?: <Is it safe to leave a voicemail?>

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NATURE OF VIOLENCE  

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

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

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

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

Is there current contact between the parties: <Any contact between perpetrator and client?>

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> 
Date of birth: <Date of birth>		Gender: <Gender>
Relationship to client: <Relationship to client>
Email: <Email>			Phone: <Phone>

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REFERRING DOCTOR DETAILS

Name: <DrDetails>
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 for this referral? <Has the client provided consent for this referral?>

Is there ongoing medical treatment or health concerns that impact the vulnerability of this client? If yes, please provide details.<Other medical treatment of health concerns>

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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 this to police?: <Have you reported this to police?>
Have you reported this to Child Safety?: <Have you reported this 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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VERIFICATION

Electronically Signed: <DrDetails>
<TodaysDate>

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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 DFS, SV and CSA. This service is supported by funding from the Australian Government through Brisbane South PHN.