Safe Children. Strong Families. Supportive Communities.


Agency Referral Form

Agency Referral Form

SECTION 1 – Referral Agency details

Has the client consented to the referral?
Referral type:

SECTION 2 – Client details

Home Address *
Home Address
Female/Male *
Identifies as GBTIQ+
Does the client identify as having a Disability?

AVO Details

Is there a current AVO:

Corrections orders:

Is the client currently under supervision from NSW Corrective Services:

SECTION 3 – Referral Details

SECTION 4 – Engagement with other services

Are you aware of any other service that may be working with your client?

Mental Health
Drug and Alcohol
Is there an agency who has case management?

SECTION 5 – Helpful documents

Please provide a copy of relevant document/ to support this referral including;

1. Copy of all current AVO’s
2. Copy of Bail, Corrective Services conditions or any other Court order
3. Copy of any Court Order relating to the children
4. Children – names of all children from past and present relationships:

Attach any other relevant information. Allowed file types are: .(doc,docx,pdf,png,jpg,bmp,tiff)
Maximum upload size: 2.1MB

SECTION 6 – Sign off

Acceptance *

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We need your help

Kempsey Families welcomes your support of our programs and community events.

This extra support enables us to continue providing services to women, children, young people, families, and men who are experiencing domestic violence, parenting challenges or other complex issues impacting their capacity.

We are a deductible gift recipient, with all donations over $2 tax deductible.


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Registered Charity

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

Our Funding

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

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.