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

Your Experience of Family Violence

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.

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