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Request for Adult Supportadmin2023-07-26T04:14:48+00:00

PACT Support Request for Adults

This referral provides information to volunteer PACT Support Persons to enable PACT to adequately prepare and support adult complainants or witnesses for the criminal court process. Once we receive a referral, PACT will allocate it to one of our PACT Support Persons who will be in touch with the complainant/witness.

PACT Adult Witness Referral Form

Occurrence (QP) #:

Pros. index/DPP ref #:

Date submitted:

PART 1: Adult Complainant / Witness Details

Given name(s) of complainant/witness: *

Complainant/witness first and middle name(s)

Last name of complainant/witness: *

Complainant/witness family name

Date of birth (complainant/witness): *

DD/MM/YYYY

Gender of complainant/witness:

Ethnicity of complainant/witness:

Ethnicity of complainant/witness

*If other ethnicity, describe here:

Type of witness:

Relationship to the defendant (offender):

How is the complainant related to the defendant?

Current residential address of complainant/witness: *

Address of complainant/witness

Suburb and State: *

Postcode: *

Current phone number of complainant/witness: *

Phone # of complainant/witness

Email of complainant/witness:

Email of complainant/witness

PART 2: Defendant's Details

Defendant's Given name(s):

Defendant's Family name:

Defendant's date of birth:

Offender's DOB: DD/MM/YYYY

What was the date of arrest?

DD/MM/YYYY

PART 3: Police Officer's Details

Police Officer's given name(s):

Police Officer's last name:

Rank:

Reg. no:

Police station:

Police Officer's phone no:

Police Officer's email:

Part 4: Court/Case Details

Court date:

DD/MM/YYYY

Court details

Committal Mention

Committal Hearing

Trial

Mention

Directional Hearing

Pre-recording

Awaiting indictmentAwaiting indictment

Court location (eg. Cairns District, Brisbane Magistrates):

List charges in which the complainant or witness is required to give evidence:

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

Yes

Further information:

eg: Trial number, date committed for trial, any special instructions

Part 5: Submitted By

Full name of person submitting referral: *

First name and surname of person submitting the form

Organisation of person submitting referral:

*If applicable

Phone number of person submitting referral: *

Email of person submitting referral: *

Email address of the person submitting the form

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.

Consent received

If you are human, leave this field blank.

THANK YOU FOR YOUR REFERRAL TO PACT

PACT acknowledges the Traditional Custodians of the land on which we live, work and study. We pay our respects to local Indigenous Elders past, present and emerging and recognise the strength, resilience and capacity of all Aboriginal and Torres Strait Islander people.