Self Referral

This form is designed to be used by women from migrant and refugee communities experiencing family violence.

If you would prefer to have a phone conversation please call us on 1800 755 988 9:00am- 5:00pm Monday- Friday.

inTouch is not a crisis service.

If you feel unsafe, threatened or fearful for yourself, a child or family member, please call 000. If you are in a crisis, call Safe Steps, Victoria’s 24/7 family violence response line on 1800 015 188

Your Full Name(Required)

First Last

Email(Required)

Address

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

Home Phone

Mobile Phone(Required)

Date of birth(Required)

Year of arrival in Australia

Visa Status

Gender Identity(Required)

Cultural Identity(Required)

Do you, or anyone else in your household indentify as Aboriginal or Torres Strait Islander?”(Required)

Dialect(s) / Language(s) spoken *(Required)

Do you require an interpreter?(Required)

Do you require an AUSLAN interpreter (sign language)?

When is it safe for us to call you? *Please note – all calls from inTouch will appear as a private/unknown phone number.(Required)

Is it safe for us to leave a message on your phone? (select all that apply)

It is safe to leave a voicemail message

It is safe to send a text message

It is not safe to send a text message or leave a voicemail

Your Experience of Family Violence

Please detail the most recent incident and when it occured, as well as any past history of family violence you'd like us to know about.

Do you have children in your care? If so how many and what are their name(s) and date(s) of birth?

What are your current circumstances? (For example- Do you live with the person who is choosing to use violence? Have the police or courts been involved?)

Are you currently connected with any other services? (For example: The Orange Door, other family violence services, a lawyer, child protection, counsellors, housing providers?)

Name of the person choosing to use violence

Gender of the person choosing to use violence

Your relationship to this person

What assistance or areas of support would you like from inTouch?(Required)

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Comments

This field is for validation purposes and should be left unchanged.

Submitting this form will send the information you have provided to inTouch. An intake worker will contact you within 2 business days.

Self Referral

inTouch is not a crisis service.

Your Experience of Family Violence

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