Referral FormThis is a referral request form only. We cannot guarantee support until we verify our availability on the requested date and location. Please note we cannot assist anyone under 18 years old. Dynamics 365 "*" indicates required fields Step 1 of 4 25% HiddenEnquiry Method1800WebsiteEmailHead Office Phone CallHiddenPurpose of Support* Advocacy Book Support Information Support Who is completing this form?*Court UserSupport ServicesFamily MemberFriendCourt Networker at CourtBefore completing this form, do you give consent for Court Network to use your details to provide support?*YesDo you have the Consent of the person to provide Court Network their details?*YesReferrer's Name* Name of Support Service Referrer's Contact Number*As the Referrer, would you like to be notified of the Outcome?*YesNoPlease provide your email address so we can give you an update:* Location*VictoriaQueenslandQueensland Courts*Brisbane Family CourtFederal Circuit and Family Court of AustraliaVictorian Court*Ballarat CourtBendigo CourtBroadmeadows Magistrates CourtCastlemaine CourtChildren's Court of VictoriaColac CourtCoroner's Court of VictoriaDandenong Family CourtDandenong Magistrates CourtEchuca CourtFederal Circuit and Family Court of AustraliaFrankston Magistrates CourtGeelong CourtHeidelberg Magistrates CourtLatrobe Valley CourtMelbourne Family CourtMelbourne Magistrates CourtMildura CourtMoorabbin Justice CentreNeighbourhood Justice CentreRingwood Magistrates CourtShepparton CourtSunshine Magistrates CourtSupreme Court of VictoriaVCATWangaratta CourtWarrnambool CourtWodonga CourtWerribee Magistrates CourtHiddenWhat type of support do you need?*Network In-Court SupportOnline/Teleconference SupportTelephone Support ServiceChoose only one option.Court Date* DD slash MM slash YYYY Time for SupportMorningAfternoonAll DayNot KnownDo you require multiple court dates?*YesNoSecond Court Date DD slash MM slash YYYY Third Court Date DD slash MM slash YYYY Preferred PronounsHe/Him/HisShe/Her/HersThey/Them/TheirsZe/Hir or Ze/ZirGender*FemaleMaleNon-BinaryPrefer Not to SayFirst Name* Last Name* Contact Phone Number*Age Range*Under 25 Years OldBetween 25-60 Years Old60+ Years OldAre you of Aboriginal and Torres Strait Islander origin?*NoYes, AboriginalYes Torres Strait IslanderYes both Aboriginal and Torres Strait IslanderUnknown/Not StatedCountry of Birth*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsOtherIf other please state: Will an Interpreter be required?*NoYesPreferred Language*ArabicAustralian Indigenous LanguagesBengaliCantoneseEnglishFijianFilipinoFrenchGermanGreekHindiIndonesianItalianJapaneseKoreanMalayalamMandarinNapaliOtherPunjabiSinhaleseSpanishSudaneseTagalogTamilThaiTurkishVietnameseIf other please state: Do you have a disability that affects your participation in the court process?*YesNoWhat type of assistance would you require?*Additional ExplanationAuslan InterpreterBreaksReassurance to Stay CalmSensoryWriting/ReadingDo you have a gender preference for the Court Network employee who supports you?*YesNoPreferred gender preference*FemaleMale Do you have any immediate concerns about your safety, your children's, or someone else in your family (pet's inc.)?*YesNoPlease Provide a Brief Summary of Your Situation*Type of Court Matter*Children's CourtCivilCoronialCriminalDomestic/Family ViolenceFamily LawFederalPSIOChoose only one option.Type of Domestic/Family Violence Matter*Breach of Intervention OrderCross ApplicationFamily Violence Safety NoticeIntervention Order Application/AmendmentN/ACourt User Type*ApplicantAffected Family MemberDefendant/AccusedInvolved PartyRespondentSupport PersonVictim/SurvivorWitnessIf known, name of Accused/Defendant/Respondent:* CommentsThis field is for validation purposes and should be left unchanged.