GVCASA Self Referral

Step 1 of 3

Is this referral for you or someone else?(Required)

Is this person a child or an adult?(Required)

Date

Name(Required)

First Last

Please note, a name (can be an alias name) is required so GVCASA can contact you to organise an intake and assessment

Gender Identity

Pronouns

Date of birth

Have you ever attended a CASA service before?

Emergency: 000

Sexual Assault Crisis Line – free call 1800 806 292

SACL is staffed by counsellors specifically trained in supporting victim survivors of sexual assault.

Nurse on call: 1300 60 60 24
for non life threatening injury/illness