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If you’re in immediate danger, please call 000.

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Agency Referrals

If you're an agency worker referring a client (with their consent),please fill out the form below. Alternatively, you can download the referral form using the button below, complete it, and email it to intake@dvrs.org.au.

If this referral is urgent, please call Mackay Women’s Services via (07) 4953 1788.

Download our intake form

Client Details

Cultural Identity:

What is your preferred contact method?

Phone safety assessment:

Is it safe to call this number?

Is it safe to send a text to this number?

Is it safe for us to identify the service?

Is it safe to email this address?

Referrer Details

Reason for Referral

Is this client experiencing any of the following:

Is there a Protection Order in place?

Consent

Has this referral been discussed with the client?

Please note: Referrals will only be accepted if client has consented

Your submission has been received! Someone from our team will be in touch as soon as possible.
Something went wrong while submitting the form. If this happens again, please call our team on 07 4953 1788.

If you are in immediate danger, call 000.

For after-hours domestic and family violence support, contact the DVConnect Women’s Line on 1800 811 811.