Safe Connections Waiting List

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Waiting List Application

Interested in becoming a Safe Connections agency? Join our waiting list below.

Waiting List Application Form

Your Organisation
What is the name of your organisation?*
What is the website of your organisation?*
What is your organisation's ABN?*
My organisation is:*
Select all that apply.
- Not-for-profit
- Registered with the Australian Charities and Not-for-profits Commission (ACNC)
- Public Benevolent Institution
- Other
Please describe your organisation
In which State or Territory is your organisation based?*
Your Contact Person
Who is the best person for us to contact about this application?*
First Last
Email address*
Phone number*
Eligibility for Safe Connections program
Does your organisation provide frontline services?*
- Yes
- No
Are you a specialist women's or generalist service?*
- Specialist service for women experiencing gender based violence
- Generalist service that has clients who are women that may be experiencing gender based violence
- None of the above
Please describe the service(s) your organisation provides to women experiencing gender based violence. Please specify the program or service in which you would use Safe Connections phones.*
We use this information to help us understand the context in which you intend to give Safe Connections phones to your clients.
Suburb and postcodes of your locations where you would like to make Safe Connections phones available*
e.g. Melbourne 3000
Does your service or program have a risk assessment and safety planning process to inform the provision of services to women experiencing gender based violence?*
- Yes
- No
- I'm not sure what this means
How many phones do you estimate your program or service needs for women experiencing gender based violence, on average, per month?*