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Miranda Clarke

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General Enquiries

Name *

First

Last

Email *

Comment or Message *

Comment

Self Referral Form

Name

First

Last

Date of Birth:

Phone Number:

Is it safe for us to call you?

Yes
No

Would you like us to send a text message before calling?

Yes
No

When we call you, the call will come from a private phone number

When is the best time for us to phone you?

Is it safe for us to leave a voicemail?

Yes
No

Is it safe for us to send a text message?

Yes
No

Email Address:

Is it safe for us to send an email?

Yes
No

Do you live, work or study in;

Logan Region
Redlands Region
Beaudesert Region

Do you have any accessibility needs?

Is there anything else you would like for us to know?

Comment

External Agency Referral Form

Client has given consent for the referral to be made to CASV: *

Yes

Client has experienced sexual assault at some point in her life: *

Yes

Client is aged 12y and over: *

Yes

Client lives, works or studies in the Logan, Beenleigh or Redlands regions: *

Yes

Referring Agency: *

Referral Date: *

Referring/ Contact Person: *

Position: *

Referrer Phone: *

Referrer Email *

Client Name: *

First

Last

Date of Birth:

Client Mobile Number: *

Parent/Guardian Name (if applicable):

Parent/Guardian Mobile Number (if applicable):

Home Phone Number (if applicable):

Is it safe to call? *

Yes
No

Is it safe to leave messages? *

Yes
No

Is it safe to send a text message? *

Yes
No

Client Postal Address:

Postcode

Is it safe to send mail? *

Yes
No

Client Email Address:

Is it safe to send email? *

Yes
No

Client School (if applicable):

Legal Guardian (if applicable):

Disability:

Does the client have any accessibility needs?

Cultural Heritage:

Primary Language Spoken:

Is an interpreter required? *

Yes
No

Does the client identify as: *

Aboriginal
Torres Strait Islander
Both
Not Applicable

Has the client been referred to CASV in the past?

Yes
No

Reason for referral *

Therapeutic goals, recent trigger/s, support or information required

Was the sexual assault recent (within past 3 months)? *

Yes
No

Please fill this question to the best of your ability based on the information you have already received from the client

Have there been any historical sexual assault/s? *

Yes
No
Unsure

Please fill this question to the best of your ability based on the information you have already received from the client

What was the location of the sexual assault? *

Public space
Private space
Unsure

Please fill this question to the best of your ability based on the information you have already received from the client

Has the sexual assault been reported to police? *

Yes
No
Unsure

Please fill this question to the best of your ability based on the information you have already received from the client

Has any medical treatment been received? *

Yes
No
Unsure

Please fill this question to the best of your ability based on the information you have already received from the client

Has a forensic medical examination occurred? *

Yes
No
Unsure

Please fill this question to the best of your ability based on the information you have already received from the client

Did the sexual assault occur within an child institutional care setting (e.g. school, church, sporting group, foster care)? *

Yes
No
Unsure

Please fill this question to the best of your ability based on the information you have already received from the client

Would the client like assistance applying for the National Redress Scheme? *

Yes
No
Unsure

The National Redress Scheme provides support to people who experienced institutional child sexual abuse.

Gender of the perpetrator/s:

Male
Female
Unsure

Please fill this question to the best of your ability based on the information you have already received from the client

Relationship of perpetrator/s to client:

Please fill this question to the best of your ability based on the information you have already received from the client

Identified risks: *

Suicide, self-harm, substance use, domestic violence, mental health issues, ongoing harm or risk of harm

Further information:

Phone