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Sexual and Institutional Abuse Registration Form

1. Your details:

First Name*:
Last Name*:
Maiden Name:
Any other first or last name(s) used:
Date of birth:
Sex:
Address:
Daytime telephone No.:
Email*:
Mobile*:

2. Institution(s) where abuse occurred:

  • Please give the names and addresses of all institutions in which you were resident/attended and the relevant dates as precisely as possible.
  • Please also state, if you can, any number you were given in the institution.
Name of Institution: Address: Dates of residence/attendance:
From: To:
Number given in the institution:

3. Description of abuse suffered by you:

  • Please provide a written account of any sexual, physical or emotional abuse or any neglect which you suffered.
  • Please provide the following details, if you can
Place(s) where abuse occurred Approximate date(s) when abuse occurred: Name(s) of person(s) who committed abuse:

4. Description of injuries resulting from abuse:

  • Please provide a written account of the injuries resulting from the abuse with reference to the following:
(a) Physical or psychiatric injury.
(b) Psychological, social and educational difficulties.
(c) Loss of employment or other opportunity
  • If you have attended any medical or other practitioner or any hospital for treatment of these injuries, please provide the following information where possible:
Name of Practitioner/hospital: Address: Dates attended:

5. Civil or criminal proceedings arising from abuse:

Have you ever made a statement to the police about the abuse suffered by you?
If "yes" please give details
Name of police officer:
Police station:
Date when statement made:
Address of police station:
Have you brought any proceedings for damages against any person or body arising out of any matter referred to in this form?
Have you received damages by way of a settlement or a court award in respect of any action arising out of any matter referred to in this application?
If yes, what is the amount of compensation/damages received?

6. If you wish to add anything to the information you have given above, please do so in the space below:

7. Tell us about yourself:

Were you a Ward of the State?
If so, over which years? to
Are you married?
Do you have children?
Child 1 Date of birth
Child 2 Date of birth
Child 3 Date of birth
Child 4 Date of birth
Child 5 Date of birth
Child 6 Date of birth
Do you have siblings?
Were they in the Institution with you?
Are you in contact with them?
Can you provide contact details?
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Are you in contact with any other residents who were in the Institution with you?
If yes, please provide contact details:
What level of education did you achieve?
Are you presently employed?
What is your occupation?
Name of Employer?
Average Gross Annual Earnings?
How did you hear of our office?

captcher

Address:

247 Park Street, South Melbourne, Vic 3205
PO Box 42, South Melbourne,VIC 3205
Phone: (03) 9686 6610

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