Make a Referral

Make A Referral

To receive support from PACT, a referral is required. This helps us understand your court matter and match you with an appropriate volunteer.

Please complete the referral form below.

"*" indicates required fields

Step 1 of 8

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Occurrence (QP) #*

If you do not know the QP number, we recommend contacting your arresting officer to confirm this information or have them submit a referral on your behalf.

Type of service required*

Complainant/Witness Details

Given name(s) of complainant/witness*

Last name of complainant/witness*

Gender of complainant/witness*

Complainant/Witness Date of Birth*

DD slash MM slash YYYY

Ethnicity of complainant/witness*

Type of witness*

Relationship to the defendant (offender)*

Address of complainant/witness*

Street Address Address Line 2 State / Province / Region ZIP / Postal Code

Phone number of complainant/witness

Email of complainant/witness

Carer's Details

To be completed for minors only

Carer's given name(s)*

Carer's first and middle name(s)

Carer's last name

Carer's family name

What relationship is the carer to the child?*

Carer's current residential address*

Same as the complainant

Street Address Address Line 2 State / Province / Region ZIP / Postal Code

Carer's current phone number*

Carer's email address*

Does the complainant/witness have a Child Safety Officer assigned?*

Child Safety Officer Details

Child Safety Officer's given name(s)

Child Safety Officer's last name

Child Safety Office

Child Safety Officer's current phone number

Child Safety Officer's email

Defendant's Details

Defendant's given name(s)*

Defendant's last name*

Defendant's date of birth*

DD slash MM slash YYYY

Date of arrest*

DD slash MM slash YYYY

Police Officer's Details

Police Officer's given name(s)*

Police Officer's last name*

Rank

Registration number*

Police station*

Police Officer's phone number*

Police Officer's email*

Court/Case Details

Court Event*

If you do not know which option to select, we recommend contacting your arresting officer to confirm this information or have them submit a referral on your behalf.

Court Jurisdiction*

Court Location*

(e.g. Cairns, Gladstone)

Court date*

DD slash MM slash YYYY

Date Committed to Higher Court*

DD slash MM slash YYYY

List charges in which complainant/witness is required to give evidence*

Are these historical charges?*

Are there any problems with this case that are not listed on this form?*

Further information

Submitted By

First name of person submitting referral*

Last name of person submitting referral*

Organisation of person submitting referral

Phone number of person submitting referral*

Email of person submitting referral*

Consent*

Consent received

The complainant/witness has given permission for the Office of the Director of Public Prosecutions, the Queensland Police Service, and Protect All Children Today to obtain, share and provide information between organisations for the complainant/witness listed in this referral form.