Genie Safety PROFESSIONAL REFERRAL Home Genie Safety PROFESSIONAL REFERRAL Professional Referral – Genie Safety Hub Full Name Organisation Role/Title Phone Number Email Referral Date Full Name of Client Preferred Name (if known) Age Is the client aware of the referral? Yes No Client Contact Number (if safe to use): Preferred Time & Method of Contact: Does the client identify as Aboriginal or Torres Strait Islander? Yes No Preferred language / Interpreter needed? Yes No If yes, specify language Please outline the presenting concerns, including risk factors, history, protective factors, existing support services, or known triggers. Services Requested Safe Accommodation – Emergency or Short-Term Safety Planning Trauma Counselling Enhanced Maternal & Child Health Support Men’s Behaviour Change Support or Positive Behaviour Coaching Supervised Contact Other Services (please specify) Urgency Level High – Immediate safety concern (Same-day response required) Medium – Action required within 24–48 hours Low – Non-urgent Has the client consented to share this information? Yes No Are you attaching supporting documents? Yes No Not Applicable Include any special instructions, cultural or disability-related considerations, or agencies involved in care. Send