If you are, or someone you know is, in Victoria and experiencing elder abuse, call our confidential helpline on 1300 368 821.

Seniors Rights Victoria > Get help for yourself or someone you are concerned about > Self-referral form

Self-referral form

THIS FORM IS IN A TESTING PHASE AND SHOULD NOT BE USED AT THIS TIME. COMPLETED FORMS WILL NOT BE ACTIONED BY OUR HELPLINE AT THIS TIME. INSTEAD, CALL OUR HELPLINE ON 1300 368 821.

This form is to request a call from with Seniors Rights Victoria. You will be responded to within two (2) working days. For safety reasons, we call from an unknown or private number. If you don’t answer we will leave a message if you have indicated it is safe to do so.

If you are in immediate danger, please contact 000.

If you are unable to provide a time that is safe to call you about this form, please do not complete it. Instead, call our Helpline on 1300 368 821 at a time that is convenient and safe for you.

By completing this form, you consent or SRV to contacting you on your preferred contact method. Your information will be collected and stored in accordance with our privacy policy.

Self-referral form

Your information

Please provide us with information about yourself.

Do you think you may be experiencing elder abuse?

This can include physical abuse, sexual abuse, pressure to give money, pressure to hand over property, isolation, not being able to pay bills, not having access to food, not having heating or cooling, or name calling.

 

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