Safer in the Home

Referral form

​Safer in The Home provides funding for basic security upgrades to low to medium risk range.

​This form is to be completed by referrers only.

If you are not a referrer or need more information, contact us at 1300 694 167 (9.00am to 5.00pm AEST Monday to Friday – closed public holidays).

For housing support (including emergency accommodation), material aid, and ongoing case management call:

• 13 SALVOS (13 72 58)
• 1800 RESPECT (732 732)

1. Referrer Details

A referrer includes specialist domestic family services, police and support workers.

Organisation Name **
Referrer First name **
Referrer Last name **
Referrer Phone number **
Referrer Email ***

2. Applicant details

The applicant details are to be provided by the referrer.

Consent

Has the applicant given consent to share their information with us for the purpose of this referral? Yes No

Applicant contact details

Applicant First name **
Applicant Last name **
Date of birth *
If date of birth unknown, what is their approximate age? *
Gender Female Male Non-binary Prefer not to answer Other
Other gender *
Applicant Phone number **
Applicant Email **
Address **
Suburb **
State or Territory * Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia
Postcode **

Who lives at the property with the applicant? *
What is the property type? Community housing High-rise apartment Owner-occupied Public housing Private rental Share house Unknown Other
If other, please specify *
Does the applicant need a remote tech "sweep"? Yes No I don't know
What operating system are they using and how many devices? *

3. Information to help us provide support

The following help our team to provide the required support services. Some questions are for data collection and do not impact the eligibility of the applicant.

What other support services is the applicant receiving? *
Does the applicant identify as living with disability? Yes No
If yes, provide further details *
Does the applicant identify as: Aboriginal Torres Strait Islander Both Aboriginal and Torres Strait Islander Culturally and linguistically diverse (CALD) None of the above Prefer not to answer
What is their country of birth? *
If not born in Australia, what year did the applicant arrive in Australia? *
Is English their preferred language? Yes No
If no, does the applicant require an interpreter? Yes No
If yes, which language? *
What is the income source for the applicant? Centrelink benefits Employed Other
Other, please specify *

Emergency contact (optional)

First name *
Last name *
Phone *
Relationship to applicant *

4. Risk assessment

Specialist family violence services should use a risk assessment specific to the applicant's state or territory.

Have you completed your organisation's risk assessment? * Yes No
If yes, upload the risk assessment along with supporting documentation below. *
If no, complete the following risk assessment *
What is the relationship with person using violence? *
Where are they located? *
When did the most recent situation occur? Provide a summary of the event. *
Which of the following has the applicant experienced?
Is an intervention order currently in place? Yes No Not Now
If yes, what is the expiry date of the intervention order? *
Has the intervention order ever been breached? Yes No I don't know
Have they controlled the applicant’s day-to-day activities (who they see, where they go) or put them down? Yes No I don't know
Is more than one person making the applicant feel afraid (multiple perpetrators)? Yes No I don't know
Is the person using violence currently unemployed? Yes No I don't know
Additional comments *

Recency

Have they recently done any of the following?
Do they misuse alcohol, drugs or other substances? Yes No
Additional comments *

Perpetrator actions against the applicant

Have they controlled their access to money or had a negative impact on their financial situation? Yes No I don't know
Have they physically harmed them? Yes No I don't know
If yes, what type of harm? *
Have they assaulted them when pregnant? Yes No I don't know
Have they tried to choke or strangle them? Yes No I don't know
Have they threatened to kill them? Yes No I don't know
Do they have access to weapons? Yes No I don't know
Have they threatened or used a weapon against them? Yes No I don't know
Have they forced them to have sex or participate in sexual acts when they did not want to? Yes No I don't know
Have they harmed or threatened to harm their pet or animal? Yes No I don't know
Additional comments *

Risk to children

Is child protection involved? Yes Previously involved Never involved
Has the person using violence ever harmed or threatened to harm the applicant’s child or children? Yes No I don't know
Have the applicant’s children ever been present during or exposed to family violence incidents? Yes No I don't know
Additional comments *

Safety

Has the person using violence been convicted of a crime? Yes No I don't know
Would the applicant engage with police if they felt unsafe? Yes No I don't know
Has a safety plan has been discussed with applicant? Yes No I don't know
Additional comments *

5. Document upload

You can provide your documents in any one of these formats: word (.docx), pdf, jpeg, jpg, tiff, png or gif

File(s):You can upload a maximum of 5 files, each up to 1000KB. Supported files include pdf, jpeg, jpg, tiff, png, gif, docx, doc, .jpeg, .jpg, .tiff, .png, .gif, .pdf, .docx, .doc.

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We aim to respond to all referrals within one business day. If you have any questions about eligibility or submitting a referral, email saferinthehome@salvationarmy.org.au