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The Women's Safety Program welcomes referrals from community organisations and other professionals.

If you have a client who you feel could benefit from this program, please complete and submit the online referral form below. Please note this form is to add your client to the waiting list, their enrolment into a group is not guaranteed.

After completing this form your client will be contacted by one of our staff to confirm details and talk to them about the program to ensure it is right for them. We will also get back to you directly to confirm that we have been able to get in contact with your client.

Any information provided in this form is private, confidential and stored securely.

Is this right for your client?

The Women's Safety Program is an educational program that delivers workshops on safety and wellbeing topics.

At times we will talk about topics that can potentially trigger clients if they are too close to their trauma or still in recovery. We do not provide therapeutic outcomes however we deliver content in sensitive and compassionate manner.

If you are concerned this program may not be right at this point in time for your client or you would like more information before completing this form please email or call 6176 3470

Client Consent

Referring Agent Information

For example Case Manager, Support Workers, Counsellor etc

Client Information

Client Address
When we need to contact the client, is it safe to or do they have a preference?

About Your Client

Is your client 18+ years of age?
Is the client (or does the client identify as) a woman?
Client Employment Status
Is your client of Aboriginal and/or Torres Strait Islander origin?
Does the client live in Canberra or Surrounds (eg., Queanbeyan, Yass, Goulburn)
Is the client willing and able to undertake travel on a weekly basis to attend the classes? This includes classes on a Tuesdays or Wednesdays.

Program eligibility category

Why we ask these questions? The Women's Safety Program is funded by one of the Department of Social Services' (DSS) Strong and Resilient Communities Activity - Inclusive Communities (SARC) grants which exist to: "support vulnerable and disadvantaged people on pathways to self-reliance and empowerment through local community-driven solutions that support them to participate socially and economically". The SARC Women's Safety Program was developed as a preventative program for women with disability, impairment or are in a 'vulnerable' or 'at-risk' category. We ask these questions as a screening tool to ensure eligibility, but also for reporting purposes to DSS. Information reported to DSS is done in an anonymous way to respect the privacy of individuals so that no personal identifying information is provided with demographic statistics.

Please answer the below about the client you are referring to the Women's Safety Program


Sensory impairment / Disability (Tick all that apply)
Physical Disability (Tick all that apply)
'Vulnerable'/ 'at-risk' category (Tick all that apply)

Client Accessibility Needs

Will the client have a support person/carer attending the sessions?
Will the client have a Guide Dog, Assistance/Service Dog?

Client Safety Concerns

Is the client currently in an unsafe or crisis situation?


Which 10-week group did you want your client to enrol into?
Click or drag a file to this area to upload.

Everything shared in this form is private, confidential and stored securely for yourself and the client.

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