Motivation for Change

Are You(Required)

a person looking to enrol in Motivation for Change Men’s Behviour Change Program

a professional referring a client Motivation for Change Men’s Behviour Change Program

Referrer’s details

Date(Required)

First Name(Required)

Last Name(Required)

Organisation & Position(Required)

Phone / Mobile(Required)

Email(Required)

Risk Assessment

Are you from a Specialist Family Violence / Mandated Agency(Required)

Yes

No

MARAM Risk Assessment *(Required)

Max. file size: 20 MB.

Copy of L17s(Required)

Max. file size: 20 MB.

Current Safety Plan(Required)

Yes

No

Please Attach(Required)

Max. file size: 20 MB.

Involvement with other Service Providers

Agency Name

Contact Person

Phone/ Mobile

Email

Service accessed

Current Case Plan

Yes

No

Please Attach(Required)

Max. file size: 20 MB.

Please provide details of identified attitudes, beliefs and behaviours that require attention

Client Details

First Name(Required)

Last Name(Required)

Phone / Mobile(Required)

Email(Required)

Primary Address(Required)

Current Location (if not primary address)

Date of Birth(Required)

Age (if known)(Required)

Preferred language(Required)

Interpreter required(Required)

Yes

No

Ethnicity/Cultural Background(Required)

Country of Birth(Required)

Visa Status and Type(Required)

Year of arrival in Australia(Required)

Identifies as having disability(Required)

Yes

No

Not Known

Source(Required)

Detail(Required)

Emergency Contact Name(Required)

Emergency Contact Number(Required)

Relationship to Victim Survivor(Required)

Adult Victim Survivor (As per the most recent FV incident)

Date(Required)

First Name(Required)

Last Name(Required)

Country of Origin(Required)

Ethnicity/Cultural Background(Required)

Phone / Mobile(Required)

Address(Required)

Current living arrangements(Required)

Live with Person Using Violence

Living separately

Cannot disclose

Which arrangements do children from current/previous relationships live in?

Live with Adult victim survivor

Please provide Names and Date of Birth of all children that live with the Adult Victim Survivor(Required)

⁠Please confirm the number of children living with the Adult Victim Survivor(Required)

⁠Please provide any other relevant details for the children living with the Adult Victim Survivor(Required)

Live with Person Using Violence

⁠Please provide Names and Date of Birth of all children that live with the Person Using Violence(Required)

⁠Please confirm the number of children living with the Person Using Violence(Required)

Please provide any other relevant details for the children living with the Person Using Violence(Required)

Live elsewhere

⁠Please provide Names and Date of Birth of all children that live elsewhere(Required)

Please confirm the number of children that live elsewhere(Required)

⁠Please provide any other relevant details for the children that live elsewhere(Required)

Preferred language(Required)

Interpreter required(Required)

Yes

No

Visa Status and Type(Required)

Year of arrival in Australia(Required)

Details of Legal Circumstances

Domestic Violence / Invention Order

Yes

No

Please upload a copy

Max. file size: 20 MB.

Protective Orders

Yes

No

Please upload a copy

Max. file size: 20 MB.

Family Court Orders

Yes

No

Please upload a copy

Max. file size: 20 MB.

Criminal charges including impending charges?

Current interim Intervention Order?

Any other relevant information useful for Risk Assessment and Management

Upcoming Court Dates

Yes

No

If yes please provide details

Client Consent

Has the program been explained to the Client/Participant?(Required)

Yes

No

Has the client consented to this referral?(Required)

Yes

No

Preferred contact time and method(Required)

Date(Required)

Motivation for Change

Web Referral Form

Referrer’s details

Risk Assessment

Involvement with other Service Providers

Client Details

Adult Victim Survivor (As per the most recent FV incident)

Which arrangements do children from current/previous relationships live in?

Identified Behaviours

Details of Legal Circumstances

Client Consent

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