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*Please note:

If you are submitting this referral on another person's behalf, you must have their verbal or written consent before doing so.

Please obtain consent before submitting this referral. Thank you.

Please select your location

Court Date*

Court*

Given Name/s*

Family Name*

Email

Phone*

Cultural Background

Preferred Language

Gender: M/F *

ATSI* (Are you of Aboriginal and/or Torres Strait Island Origin?)

Name of Referrer

Email (of Referrer)

Phone (of Referrer)*

Court User Name*

Email (Court User)

Phone (Court User)*

Cultural Background

Preferred Language

Gender: M/F *

ATSI* (Is the court user of Aboriginal and/or Torres Strait Island Origin?)

Matter*

Intervention Order Criminal VCAT Family Law Civil Other/Unknown

Name of Victim / Witness

Name of Defendant/Accused

Name of Applicant/Affected Family Member

Name of Respondent

Support Needs

Given Name/s*

Family Name*

Email

Phone*

Cultural Background

Preferred Language

Gender: M/F*

ATSI* (Are you of Aboriginal and/or Torres Strait Island Origin?)

Name of Referrer

Email (of Referrer)

Phone (of Referrer)*

Court User Name*

Email (Court User)

Phone (Court User)*

Cultural Background

Preferred Language

Gender*

ATSI* (Is the court user of Aboriginal and/or Torres Strait Island Origin?)

Matter*

Domestic & Family Violence Criminal Civil Other/Unknown

Name of Victim / Witness

Name of Defendant/Accused

Name of Applicant/Affected Family Member

Name of Respondent

Support Needs

Please note that this form authorises Court Network to send you correspondence by mail, electronically or by SMS. You can revoke this authority at any time by instructing us in writing.

Court Network complies with the relevant State and Commonwealth Privacy legislation.

All details, unless otherwise authorised, will be kept confidential and are for internal purposes only.

By clicking on the Submit button below you acknowledge your understanding of the above terms.

Please Note

If support is required within the next 48 hours, please call our Victorian or Queensland office.

VIC: 1800 681 614

QLD: 1800 267 671

If you are an adult Victim, Witness or Support Person of a Victim of Violent crime in Queensland please click here.

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