WJN Mentoring Referral Form PLEASE FILL IN ALL FIELDS Referrer Details Referrer First Name: Referrer Last Name: Referrer's Organisation: Referrer's Position: Referrer's Phone: Referrer's Email (a confirmation will be sent to this address): Client Details First Name: Last Name: Alias: Date of Birth: Gender: FemaleIntersex LSIR (if available): Cultural Background: -- None --AustralianAboriginal and Torres Strait IslanderPacific IslanderVietnameseOther MIN: Street: Suburb: Postcode: State: -- None --NSWVICNTQLDWASAACT Telephone: Program Eligibility Please select at least 1 of the 3 options below: In contact with the CJS: Committed a previous offence: At risk of custodial sentence: Current Living Situation: -- None --Private rentalTransitional centreAOD rehabilitationCorrectional centreCrisis accomodationTemporary accomodationHomelessHousing NSW property Current Legal Status: --None--BondCurrent contact with CJSIn custodyParolePrevious contact with CJSProbationSuspended sentence Custodial History First time in custody: --None--YesNo Most recent conviction: Length of most recent conviction: Date released from custody: Number of previous incarcerations: History of violence: History of a sex offence: Why would this woman benefit from a mentor: I acknowledged that the referred client is voluntarily seeking support, currently residing within the Sydney Metropolitan Region and is 18 or over: Is the person aware this referral is being made? --None--YesNo How did you hear about WJN's Mentoring Program? --None--CSNSWRehabilitation/ Housing ServiceWord-of-mouthCommunity AgencyOther Other, please state: Please note a confirmation email will be sent to the listed email address. back to top ↑