Client Referral Form

This online form may be used by practitioners to refer eligible clients to inTouch for specialist inLanguage, inCulture family violence case management and co-case management services.

Referrals for case management services should occur through a warm or supported process to maximise the likelihood that the client will take up the service and support being offered. Please continue to work with your client until our intake team replies with an assessment outcome to confirm if we are the most suitable service for the victim survivor. Our intake team prioritise assessments based on level of risk and needs of victim survivors and will endeavour to get back to you as soon as possible.

If you are a woman experiencing family violence please use our Self-Referral Form to request support from inTouch.

Details of person requesting referral

Your Full Name(Required)

First Last

Job Role(Required)

Agency(Required)

Email(Required)

Phone(Required)

Please attach most current MARAM, Safety Plan and any other files relevant to the client (Please note: this is a requirement for all family violence service providers and preferred for all other services)

Drop files here or

Accepted file types: word, jpeg, pdf, Max. file size: 20 MB.

Details of Client

I affirm that I have received the client's verbal consent to refer her to inTouch(Required)

Client's Full Name(Required)

First Last

Current Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Date of Birth(Required)

Visa Status(Required)

Gender Identity(Required)

Does the client, or anyone else in the household indentify as Aboriginal or Torres Strait Islander?(Required)

Cultural Identity(Required)

Dialect / Language Spoken(Required)

Would the client prefer to receive support from a case manager with the same background?(Required)

Year of arrival in Australia (if known)

Is an interpreter required?

Does the client require an AUSLAN interpreter?

Safe time to call(Required)

Is it safe to leave a message?(Required)

SMS/Voicemail Consent

If after 3 attempts inTouch is unable to make telephone contact with the woman, does she consent to inTouch sending her an SMS or Voicemail message with inTouch’s contact details so that the woman can make contact when she is ready? Select all that apply. *Please inform the client that all calls from inTouch will appear as a private/unknown phone number.

Send SMS

Leave Voicemail

Do Not Send SMS/Leave Voicemail

Person Choosing to Use Violence

Name of Person Choosing to Use Violence (PCUV)

First Last

PCUV's Date of Birth

PCUV's Gender

PCUV's Relationship to Client

What is the client/victim-survivors' primary concerns and needs? Please also advise of victim-survivors' current circumstances (eg. are they residing with the PCUV, are there any court orders in place?)(Required)

What is the most recent family violence incident and date it occurred? Please also advise of any previous family violence the victim survivor has experienced(Required)

What other services (if any) is the victim/survivor currently engaged with? (For example: The Orange Door, other family violence services, a lawyer, child protection, counsellors, housing providers?)

Does the client have children in her care? If so, please detail names, ages and dates of birth

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Submitting this form will send a new client intake request to inTouch.

Client Referral Form

Details of person requesting referral

Details of Client

Person Choosing to Use Violence

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