info@kempseyfamilies.org.au 02 65631588
Emergency Call 000 Quick Exit
Safe Children. Strong Families. Healthy Communities.

Client Intake/Referral Form

For individuals to make a self referral or agencies to refer a client, please use this form to make a referral. For referrals to our Men’s Behaviour Change Program called Engage2Change please use the MBCP referral form.

All personal information is treated in strict accordance to our Privacy Policy.

Client Referral Form
Address *
Address
City
State/Province
Zip/Postal
Country
Female/Male *
Disability *
Do you have children? *
Is this referral about a domestic and family violence issue?

Partner/Ex-Partner/Carer/Guardian

Because you confirmed this referral about a Domestic and Family Violence issue, please use the Partner/Ex-Partner/Carer/Guardian section to list the name and contact details of the alleged perpetrator.

Address
Address
City
State/Province
Zip/Postal
Country
Female/Male *
Relationship to Client *

Referral Details

Self Referred *
Other agencies involved? *
Attach any other relevant information. Allowed file types are: .(doc,docx,pdf,png,jpg,bmp,tiff)

Maximum file size: 20MB

Acceptance *

Section

Acknowledgment 

Kempsey Families Inc. acknowledges the Traditional Custodians of all of the lands on which we meet and work. We pay our respects to First Nations peoples and elders past, present and future. Always was, always will be, Aboriginal land.

flag flag flag

Our Funding

We are funded by the NSW Department of Communities and Justice.

 

Registered Charity

We are a registered charity with the Australian Charities and Not-for-Profits Commission (ACNC)

How to contact us

Our Main Office Location
 21 Verge Street, Kempsey

Phone: (02) 6563 1588

 

Our Vision

Our vision is for a safe, equitable and inclusive society where children, families and communities are safe, healthy, resilient and connected.