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Claim number

 
Application for counselling by a family
member of a homicide victim
Pursuant to Section 21 Victims Support and Rehabilitation Act 1996,
a family member of a homicide victim may apply for an initial period of up to 20 hours counselling.


  Note: Fields with light yellow background are mandatory.

 This form is for counselling only. If you are applying for compensation and counselling, please complete the Application for Compensation by a Family Member of a Homicide Victim.

PART 1: Details of the family member applying for counselling		 
 
 
1.
Surname Given names
2.
Date of birth 3. Gender Male Female
4.
Address Postcode
Email
e-mail copy of application to this e-mail address
Phone no. Daytime Mobile
 
 PART 2: Details of person applying on behalf of the above family member (if applicable)
      For example, if the victim is under 18 years or incapacitated.		 
 
 
5.
Surname Given names
6.
Your relationship to the family member Parent Other
Please specify
7.
Reasons for acting on behalf of the family member Victim under 18 yrs Other
Please specify
8.
Address Postcode
Phone no. Daytime Mobile
 
 PART 3: Details of the solicitor (if applicable) 
 
 
9.
Name of solicitor/firm

Note: If you have a solicitor representing you in this application all correspondence will go to them.

Address Postcode
Email
e-mail copy of application to this e-mail address
Phone no. Fax
 
 PART 4: Additional information for statistical and planning purposes 
 
 
10.
Are you of Aboriginal or Torres Strait Islander origin? No Yes, Aboriginal Yes, Torres Strait Islander
 
 PART 5: Details of the homicide victim 
 
 
11.
Surname Given names
12.
Date of birth
13.
Date of death
14.
Your relationship to the deceased
 
 PART 6: Details of the homicide 
 
 
15.
Where in NSW did the homicide occur?
(If full address is not known, the suburb/town must be provided.)

Address Postcode
16.
Which police station was it reported to?
Name of police officer (if known)
17.Briefly describe what happened.

 
  7: 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 
 
 
18.
Would you like us to allocate an approved counsellor on your behalf? Yes No
19.
Please provide the name of the approved counsellor of your choice
20.
Please let us know of any counselling preferences you have.

suburb(s)/town(s) for attending counselling   
language for counselling  
counsellor gender  
 Male Female
Type of disability access (if required)  
Other   
 
Please note that all efforts will be made to meet your preferences.

 
 PART 8: Applicant's declaration 
 
 
I hereby apply for 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 Victims Services for the purposes of subsequent counselling 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 your application for counselling will be given to you or your solicitor within two working days.

  We recommend that you print this webpage for your records.

  

 
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