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Family Harm Crisis Support

Sexual Harm Crisis

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Type of referral *

Self-Referral

Agency Referral

Only complete this section if you are an agency/person making a referral on behalf of a client.

Referral written by/emailed by *

Referrer Email *

Referrer Phone *

Referrer Organisation

Referrer Address

Date

Client has consented to referral? *

Yes

No

Do you currently feel safe? *

Yes

No

If you are concerned about your immediate safety, then please call 111

Full Name *

Phone *

Email *

Full Address *

Date of birth *

Gender *

Preferred Pronouns

Ethnicity *

Okay to leave a message?

Text

Voicemail

Email

No

Next of Kin Name *

Next of Kin / Emergency Contact *

I would like to engage in:

Crisis Support for Sexual Harm

Crisis Support for Family Violence

Counselling (for Family Violence, Sexual Harm, and/or Trauma)

Group Support (e.g. Women's Group, Youth Group, Sexual Harm Group)

ACC Counselling

Do you have any health or accessibility needs for us to be aware of? *

No

Yes

Please specify your health or accessibility needs *

Please briefly tell us a bit about your situation and how we can support you *

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Other Resources

In an emergency or if you feel your safety is at risk, please call 111.

Emergency call 111

Safe to Talk

24/7 trained specialists for sexual harm.

or

Need to talk

24/7 mental health support from a trained counsellor.

or

Youthline

24/7 support for youth.

or

Suicide Crisis Helpline

24/7 support from trained specialists.

or

Get in touch

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