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Application for
2 hours of counselling
(Section 21 Victims Support and Rehabilitation Act 1996)
 
   
Claim number

 
   
 PART 1: Details of victim Note: If you are a family member of a homicide victim, please contact us for the appropriate form. 
 
 
1.
Have you already applied for victim's compensation for this act of violence?

No Yes
==> If Yes, please provide the claim number    
2.
Surname Given names
3.
Date of birth 4. Gender Male Female
5.
Address Postcode
E-mail
e-mail copy of application to this e-mail address
Phone no. (Daytime) Mobile
6.
Your solicitor (if you have a solicitor representing you in this application all correspondence will go to them.)
Name of solicitor/firm
Address Postcode
E-mail
e-mail copy of application to this e-mail address
Phone no. (Daytime) Fax
 
 PART 2: Details of person applying on behalf of the above victim (if applicable)
      For eg, if the victim is under 18 years or incapacitated.		 
 
 
7.
Surname Given names
8.
Your relationship to the victim Parent Other
Please specify
9.
Reasons for acting on behalf of victim Victim under 18 years Other
Please specify
10.
Address Postcode
E-mail
e-mail copy of application to this e-mail address
Phone no. (Daytime)   Mobile
 
 PART 3: Additional information 
 
 
11.
What language do you speak at home?
12.
Are you an Aboriginal or Torres Strait Islander? No
Yes, Aboriginal
Yes, Torres Strait Islander
Both Aboriginal & Torres Strait Islander
13.
Were you the victim of a 'hate' crime? No Yes

==> If Yes, please specify
For eg, violence based on your culture, ethnicity, gender, religious belief or sexuality.

Culture Ethnicity Gender Religious belief Sexuality

 
 PART 4: Police information 
 
 
14.
Was the matter reported to the police? Yes No
15.
If so, what police station was it reported to?
16.
Date Reported
COPS Event No.
(if known)		E
17.
Name of offender? (if known)
18.
Is this act of violence related to domestic violence? No Yes
 
 PART 5: Details of the act(s) of violence 
 
 
19.
When did the act(s) of violence happen? Date   
Or, over a period of time From      To  
20.
Where in NSW did the act(s) of violence happen?
(If full address is not known it is important to provide suburb/town)

Postcode

21.Briefly describe what happened, including the injuries you received.

 
 PART 6: Details of counsellor A list of approved counsellors is available on our website: www.lawlink.nsw.gov.au/vs   Go To List of Approved Counsellors in NSW 
 
 
22.
Would you like us to allocate an approved counsellor on your behalf? Yes No
23.
If No, please provide the name of the approved counsellor of your choice
24.
Please let us know of any counselling preferences you have.

suburb(s)/town(s) for attending counselling   
language for counselling  
counsellor gender  
 Male Female No gender preference
Type of disability access (if required)  
other preferences   

Please note that all efforts will be made to meet your preferences.


 
 PART 7: Applicant's declaration 
 
 
I hereby apply for 2 hours of counselling pursuant to section 21 of the Victims Support and Rehabilitation Act 1996. I am aware that the contents of my counselling session may be used in the preparation of a report to the Victims Compensation Tribunal for the purposes of subsequent counselling and/or compensation applications.
Full name of the person completing this form Dated
If you have completed this form on behalf of the applicant, please enter reasons.
 

    What happens next
   A decision regarding the approval of counselling should be given to yourself, or your solicitor (if you have a solicitor representing you in this matter) within two working days.


  We recommend that you print this webpage for your records, particularly if you chose not to have a copy of the application e-mailed to you.

  

 
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