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Quick Exit
Redress Referral Form
REFERRING ORGANISATION DETAILS
Date Referred
Name of Organisation
Contact Person
Phone Number
Email
CLIENT DETAILS
First Name
*
Last Name
*
Gender Identity
*
Female
Male
Other
Prefer not to say
Date of Birth
*
Does the client identify as any of the following?
Aboriginal
Torres Strait Islander
Both Aboriginal & Torres Strait Islander
Australian South Sea Islander
CALD
Country of Birth
*
Language spoken at home
*
Does the client require an interpreter?
*
Yes
No
Address
*
Suburb
*
State
*
Postcode
*
Email
*
Phone Number
*
Does the client have a disability?
*
Yes
No
Will the client require support to access the service?
*
Yes
No
If YES, please provide details
Additional Information
How would the client like to receive information from us?
Post
Phone
Text Message
Other
If by POST, please provide a postal address
If by PHONE, is it safe to leave a voicemail?
Yes
No
If OTHER, please specify:
Please select which service/s the client requires:
Help completing a redress application
Counselling while completing a redress application
Preferred method of service delivery:
Telephone
In person (at Bravehearts Office Locations)
Outreach (in person at a different location e.g. community centre)
ehealth (videoconferencing)
Redress Eligibility
Did your abuse occur in an institution?
*
Yes
No
Was the abuse sexual in nature?
*
Yes
No
Was the client under 18 years old when the sexual abuse occurred?
*
Yes
No
Did the abuse occur before the 1st of July 2018?
*
Yes
No
Is the client an Australian Citizen or Permanent Resident?
*
Yes
No
Has the client received a payment for the abuse already?
*
Yes
No
INSITITUTION(S) DETAILS
NOTE: You do not have to provide details of the abuse here, just the institution name
Name of Institution (1)
Year range of institution
Name of Institution (2)
Year range of institution
Name of Institution (3)
Year range of institution
Other Information
Is there any other information (e.g. health conditions) that would be helpful for us to know?
Has this referral been discussed with the client?
Yes
No
Have they given consent?
Yes
No
