Eligibility Form - RAATSICC

Escaping Violence Payment Program – Individual Application

Step 1 of 7

14%

Unique ID

Submission Date (Select todays date)

MM slash DD slash YYYY

RAATSICC provides service delivery to individuals and are committed to protecting the privacy of personal information it collects, holds and administers in line with the Privacy Act 1988. RAATSICC collects and utilises a range of personal information for the purpose of conducting our program activities and in obtaining funding to deliver services.
The Escaping Violence payment is a complimentary support and not a crisis payment.

1. I am over 18 years of age(Required)

Yes

2. I am an Australian citizen, permanent resident or hold a protected special category visa.(Required)

Yes

3. I have experienced intimate partner violence in the last three months. (Intimate partner is someone you were in a romantic relationship with (eg. husband, wife, partner, boyfriend, girlfriend) Intimate partner violence can be: physical, verbal, sexual, emotional, financial abuse and coercive control.)(Required)

Yes

4. In the last 3 months I or my ex-partner have left or are planning to leave the home due to intimate partner violence. (including temporary accommodation)(Required)

Yes

5. I am experiencing financial stress due to the change in living arrangements as a result of intimate partner violence. (eg. I am unable to pay my bills, I am unable to meet my financial commitments.)(Required)

Yes

6. Have you received the Escaping Violence Payment within the last 12 months. (If you have received EVP from Uniting Vic/Tas (National EVP trial) or RAATSICC (Cairns-based EVP trial) in the last 12 months you are not eligible to apply at this time)(Required)

Yes

7. I live in the Cairns-region (Cardwell south, Cassowary Coast, Atherton Tablelands, Cairns, Cape York, Torres Strait Locations with postcodes between 4849 to 4895)(Required)

Yes

You are not eligible for Escaping Violence Payment at this time.
If your circumstances change please enquire again.

You may be eligible other support services and assistance, please Click here to for further information.

Client consent, privacy and safety.

RAATSICC provides service delivery to individuals and are committed to protecting the privacy of personal information it collects, holds and administers in line with the Privacy Act 1988. RAATSICC collects and utilises a range of personal information for the purpose of conducting our program activities and in obtaining funding to deliver services. The Escaping Violence payment is a complimentary support and not a crisis payment.

Authorisation(Required)

I authorise RAATSICC to use my details provided to assess my eligibility.

Collection of personal data(Required)

I understand that my details will be collected and stored by RAATSICC EVP and the Department of Social Services.

Case management, support and referals(Required)

I understand that RAATSICC will provide case management, support and referrals as part of the EVP process.

Withdrawal(Required)

I understand that I am able to withdraw this EVP application at any time.

ESCAPING VIOLENCE PAYMENT PROGRAM APPLICATION

SECTION 1. Applicant's details

Name(Required)

First Last

Date of birth(Required)

DD slash MM slash YYYY

Phone(Required)

Please check that you phone number is correct.

Email(Required)

Enter Email Confirm Email

If unsafe to contact directly please provide an alternative contact./p>

Name

First

Alternative phone

Alternative Email

Residential Address * Only postcodes between 4849 - 4895 are eligible for the Cairns-based EVP trial. Considerations will be made for applicants planning to move from outside the region to our service area.

Address(Required)

Street Address Town/Community Postcode Country

Cultural background(Required)

If other, please specify

Gender(Required)

If other, please specify

Do you identify as LGBTIQA+(Required)

Please specify

Citizenship(Required)

Please specify

Country of birth(Required)

Please specify

Language spoken(Required)

Please specify

Interpreter required

Are you homeless

What best describes you current housing situation

What best describes your employment type

What is your main source of Income

Do you have a long term health condition?(Required)

If other, please specify

Support services

Are you engaging with DV Specialists, Support services or other agencies?

Support service category

Support Service Name

Workers Name

First Last

Workers Phone

Workers Email

Part C - Supporting Documents

Supporting documents are required to confirm your identity. Please provide one form of photo ID (both back and front), a copy of your Medicare Card, and your most recent Bank Statement. (Bank statement provided must be a safe account that only you have access to, and the account must be in your name only).

Upload photo ID (both front and back)

Max. file size: 256 MB.

Upload your Medicare Card

Max. file size: 256 MB.

Upload your current 30 day bank statement

Max. file size: 256 MB.

Part D - Declaration

I declare to RAATSICC and the Department of Social Services that: • The information contained in this application is true and accurate. • I acknowledge that giving false or misleading information to RAATSICC and the Department of Social Services via the EVP Program is a serious offence.

Consent(Required)

YES I understand and agree to the declaration above.

An EVP intake worker will contact you in the next 2 working days between 9am and 3pm. If this call-back time is not suitable for you (eg. work commitments) please provide a preferred time.

Please tell us your preferred contact time.

Name

This field is for validation purposes and should be left unchanged.

IMPORTANT

The EVP program is not a crisis service. If you are in immediate danger, please call 000. If you or someone you know is experiencing, or at risk of experiencing, domestic, family or sexual violence call 1800RESPECT on 1800 737 732, chat online via 1800RESPECT.org.au or text 0458 737 732. For crisis support and suicide intervention please call Lifeline 13 11 14. Additional help and support options can be found in our Support and help beyond the EVP program page.

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1800 RESPECT

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LIFELINE 13 11 14

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DV Connect 1800 811 811

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What we do and where we do it.

RAATSICC provide a variety of culturally informed services to children, young people, individuals, families and carers by information sharing and providing tools to promote self determination.

As a community controlled Not for Profit organisation RAATSICC is committed to delivering services to Aboriginal and Torres Strait Islander families to make a genuine difference.

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Escaping Violence Payment Program – Individual Application