Online Referral Dynamics 365 Step 1 of 4 25% HiddenEnquiry Source(Required)1800 571 239AgencyCourt Network WebsiteCourt Networker at CourtEmailHead Office Phone CallOPP/VWASOnline HearingSafety PlansVPERHiddenCompany Name Who is the help for?(Required)Court UserHelp for Someone ElseChoose only one option.Relationship to the person(Required)FriendParent/GuardianProfessional Support PersonRelativeChoose only one option.Before completing this form, do you give consent for Court Network to use your details to provide support?(Required)YesNoChoose only one option.Do you have the Consent of the person to provide details?(Required)YesNoReferrer Name Agency Name Referrer Contact NumberAs the Referrer would you like to be notified of the Outcome?YesNoChoose only one option.Referrer Email(Required) Location:VictoriaQueenslandVictorian Court:(Required)Bacchus Marsh Magistrates CourtBairnsdale Magistrates CourtBallarat Childrens CourtBallarat Coroners CourtBallarat County CourtBallarat Family CourtBallarat Magistrates CourtBallarat VCATBendigo Childrens CourtBendigo Coroners CourtBendigo County CourtBendigo Family CourtBendigo Magistrates CourtBendigo VCATBroadmeadows Magistrates CourtCastlemaine Magistrates CourtColac Magistrates CourtCoroners Court of VictoriaCounty Court of VictoriaDandenong Family CourtDandenong Magistrates CourtDromana Magistrates CourtEchuca Magistrates CourtFamily and Federal Circuit CourtsFrankston Magistrates CourtGeelong Childrens CourtGeelong Coroners CourtGeelong County CourtGeelong Family CourtGeelong Magistrates CourtGeelong VCATHeidelberg Magistrates CourtHorsham Magistrates CourtKoorie Magistrates CourtKyneton Magistrates CourtLatrobe Valley Childrens CourtLatrobe Valley Magistrates CourtMansfield Magistrates CourtMaryborough Magistrates CourtMelbourne Family CourtMelbourne Head OfficeMelbourne Magistrates CourtMildura Childrens CourtMildura Coroners CourtMildura County CourtMildura Family CourtMildura Magistrates CourtMildura VCATMoorabbin Justice CentreNeighbourhood Justice Centre CollingwoodOffice of Public Prosecutions VictoriaOtherPhilip Island Magistrates CourtPortland Magistrates CourtRingwood Magistrates CourtShepparton Magistrates CourtSunshine Magistrates CourtSupreme Court of VictoriaSwan Hill Magistrates CourtVCATWangaratta Magistrates CourtWarrnambool Childrens CourtWarrnambool Coroners CourtWarrnambool County CourtWarrnambool Family CourtWarrnambool Magistrates CourtWarrnambool VCATWerribee Magistrates CourtWodonga Magistrates CourtWonthaggiChoose only one option.Brisbane Court:(Required)Brisbane Family CourtChoose only one option.HiddenWhat type of support do you need?(Required)Network In-Court SupportOnline/Teleconference SupportTelephone Support ServiceChoose only one option.Court Date(Required) DD slash MM slash YYYY Time for Support?MorningAfternoonAll DayNot KnownChoose only one option.Do you require multiple court dates?(Required)YesNoChoose only one option.Second Court Date DD slash MM slash YYYY Third Court Date DD slash MM slash YYYY PronounHe/Him/HisShe/Her/HersThey/Them/TheirsZe/Hir/HirsChoose only one option.First Name(Required) Last Name(Required) Contact Phone Number(Required)Court User Age RangeUnder 25 Years OldBetween 25-60 Years Old60+ Years OldChoose only one option.Gender(Required)FemaleMaleNon-BinaryPrefer Not to SayChoose only one option.Aboriginal \ Torres Strait Islander(Required)NoYes, AboriginalYes Torres Strait IslanderYes both Aboriginal and Torres Strait IslanderUnknown/Not StatedChoose only one option.Country of BirthAfghanistanAustraliaChinaFijiFranceIndiaIndonesiaIraqItalyJapanLebanonMalaysiaMyanmarNew ZealandOtherPacific IslandsPapua New GuineaPhilippinesSouth AfricaSouth KoreaSouth SudanSri LankaSudanSyriaTaiwanThailandUnited KingdomUnited States of AmericaVietnamChoose only one option.If other please state: Will an Interpreter be Required?(Required)YesNoChoose only one option.Preferred LanguageArabicAustralian Indigenous LanguagesBengaliCantoneseEnglishFijianFilipinoFrenchGermanGreekHindiIndonesianItalianJapaneseKoreanMalayalamMandarinNapaliOtherPunjabiSinhaleseSpanishSudaneseTagalogTamilThaiTurkishVietnameseChoose only one option.If other please state: Do you have a disability that affects your participation in the court process?YesNoChoose only one option.What Type of Assistance would you Require?(Required)Additional ExplanationAuslan InterpreterBreaksReassurance to Stay CalmSensoryWriting/ReadingChoose only one option.Do you have a Gender Preference for the Court Network Employee who supports you?YesNoChoose only one option.Preferred Gender(Required)FemaleMaleChoose only one option. Do you have any safety concerns?YesNoChoose only one option.Do You Have Any Immediate Safety Concern About Your Safety or Someone else in Your Family/Life/General?YesNoChoose only one option.Do You Have Any Safety or Contact Concerns? Please Let Us Know The Best Way To Contact Do You Have Post Contact Sense of Safety?YesNoChoose only one option.Engaging with Police or Trusted Person or Service?YesNoChoose only one option.Please Provide a Brief Summary of Your Situation(Required)Type of Court Matter(Required)Children's CourtCivilCoronialCriminalDomestic/Family ViolenceFamily LawFederalPSIOChoose only one option.Type of Domestic Voilence MatterBreach of Intervention OrderCross ApplicationFamily Violence Safety NoticeIntervention Order Application/AmendmentN/AChoose only one option.Court User Type(Required)Applicant/Affected Family MemberDefendant/AccusedInvolved PartyRespondentSupport PersonVictim/SurvivorWitnessChoose only one option.If known, name of Accused/Defendant/Respondent:
