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What is Consent?
Supporting someone who has disclosed sexual assault
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The Impact of Trauma on Adult Sexual Assault Survivors
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Candle Lighting Ceremony Speech 2018 – Jenny Gilmore
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Menu
Home
About us
CASV Staff
Virtual Tour
CASV Management Committee
Supporters Against Sexual Violence (SASV)
CASV Brochure
Annual Reports
Complaints Process
Services
National Redress Scheme
Information
What is sexual assault?
What is Consent?
Supporting someone who has disclosed sexual assault
Sexual Assault Reporting Options
Impact of Trauma
Self-Care
Tips for Managing Anxiety
Healthy Boundaries
Sexual Grooming
The Impact of Trauma on Adult Sexual Assault Survivors
#We Believe You
#Respect Me Too
Candle Lighting Ceremony Speech 2018 – Jenny Gilmore
Links
Events
Contact
07 3808 3299
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Self Referral Form
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Name
First
Last
Date of Birth:
Client Gender Identity:
Client Preferred Pronouns:
Phone Number:
Is it safe for us to call you?
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Would you like us to send a text message before calling?
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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?
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Is it safe for us to send a text message?
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Email Address:
Is it safe for us to send an email?
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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?
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External Agency Referral Form
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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:
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Referrer Phone:
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Referrer Email
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Client Name:
*
First
Last
Date of Birth:
Client Gender Identity:
Client Preferred Pronouns:
Client Mobile Number:
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Parent/Guardian Name (if applicable):
Parent/Guardian Mobile Number (if applicable):
Home Phone Number (if applicable):
Is it safe to call?
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Yes
No
Is it safe to leave messages?
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Yes
No
Is it safe to send a text message?
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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:
None
Intellectual/Learning
Physical/Diverse
Mental Health
Sensory/Speech
Other
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?
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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:
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