Prevention of Domestic Violence and Sexual Assault – Interview Pro Forma

As the NSW Shadow Minister for the Prevention of Domestic Violence & Sexual Assault, I want to hear your ideas, concerns and issues so that we can work together to both prevent domestic violence and sexual assault and address the consequences of violence for victims. Whatever your feedback, please complete the following details so that I can better understand the unique needs, concerns and circumstances of your organisation.

Please be assured that this is information will just be used in my policy development and formulation, and identifying data will not be distributed outside of my office without your express permission.

If you would like to meet with me or a member of my staff to further progress your issues, please let me know.

Electorate/Duty Electorate	Date
Contact type (circle one)	Service Provider Supporting Organisation Individual
Contact/Provider Name
Contact person for the Service Provider	Best Contact Number
Email Address
Electorate(s) serviced by this provider (if known)
Description of Service Provider’s issues/concerns
Service Provider’s identified needs/requests (if different to info above)
Have you/your organisation previously requested Government assistance on this issue?
Projected costing (if known)