The Eve Project Referral and Application Process

Please ensure you have read and understood the Referral Guidelines prior to completing this referral.

The EVE Project Referral Form collects information to assist The EVE Project facilitators to appropriately assist women as they undertake our trauma healing/pathways to purpose program. All information will be treated confidentially and will not be used for any other purposes than what is stated on our confidentiality statement and consent form (signed at first appointment).

Date of referral(Required)

Consent obtained for referral(Required)

yes

Please note: Referrals will not be accepted without the consent of the woman being referred. Completed referrals will be given to referred applicant’s for approval.

Referrer Details

Your Name(Required)

First Last

Organisation

Your Address

Street Address / City / State / Post Code

Phone(Required)

Email(Required)

Applicant Details

Name(Required)

First Last

Date of Birth

Address

Street Address / City / State / Post Code

Preferred Contact

Phone / Mobile

Post

Other

Phone

Applicants Next of Kin / Emergency Contact

Name

First Last

Relationship to applicant

Contact number

Applicant Details

Indigenous/Cultural Identity

Life stage (eg. single, married etc)

Any children

Please enter a number from 0 to 20.

Number of children in your care

Please enter a number from 0 to 10.

Children's Details

First Name

Last Name

Age

DOB

Childcare in place

Yes

If Yes how many days

Please enter a number from 0 to 5.

Is out-of-hours childcare available?

Yes

Childcare details

How long has the applicant been removed from the abusive relationship/situation?

GP Details

Does the applicant have an existing GP?

Yes

Same as Referrer

GP details

Name

First Last

Clinic / Surgery / Practice

Address

Street Address / City / State / Post Code

Phone

Therapist details

Does the applicant have a therapist (eg. counsellor or psychologist etc)?

Yes

Same as Referrer

Therapist Details

Name

Surgery / Practice / Clinic

Address

Street Address / City / State / Post Code

Phone

Case Manager Details

Does the Applicant have a Case Manager

Yes

Case Manager Details

Name

Phone

Other Services details

Is the applicant linked with any other services

Yes

Provide details of other services

Reasons for Referral

Please include here any information which may be useful as background information to assist with the referral. In addition to general information, please provide details about history/current status relating to the following areas

Trauma / Abuse history

Mental Health History

Drug and Alcohol Use

Vocational / Educational background

General Medical/Physical Health

Past/current risk assessments, AVO’s or ADVO’s

Please upload copies of current AVO / ADVO's

Drop files here or

Max. file size: 50 MB.

Comments

This field is for validation purposes and should be left unchanged.

The Eve Project Referral and Application Process

The Eve Project Referral / Application Form

Please ensure you have read and understood the Referral Guidelines prior to completing this referral.

Referrer Details

Applicant Details

Applicants Next of Kin / Emergency Contact

Applicant Details

GP Details

GP details

Therapist details

Therapist Details

Case Manager Details

Case Manager Details

Other Services details

Reasons for Referral