VIOLENCE PREVENTION SERVICES Referral form

incorporating the Working With the Man program

Referral type

e.g. if you're asking for help yourself, give your name. If you're referring someone else, give their name.

If you're referring yourself, what would you like us to help you with? SELF-REFERRALS ONLY - if you're referring someone else, please don't answer this question.


REFERRRAL SOURCE INFORMATION

Agency/organisation*

Select or type

COURT/LEGAL INFORMATION

Corrections supervision order?

OTHER CLIENT INFORMATION

If you're referring someone else, do you have their signed consent to exchanging information about them with EveryMan?

If you don't have signed consent

you will need to organise this. You can download a consent form from our website at https://www.everyman.org.au/storage/em-client-consent-wwm-1.pdf Call our office on 02 6230 6999 to work out the best way to send it to us. If you're a partner, family member or friend, please bear in mind that our services are confidential.

Drag and drop files here or