Domestic and Family Violence Report

Note: this report can only be used until 30 September 2021 as stated in section 3 of the Residential Tenancies and Rooming Accommodation (COVID-19 Emergency Response) Regulation 2020.

The Domestic and Family Violence Report can be completed and signed by an authorised professional to confirm that a resident is/has been experiencing domestic and family violence.

An authorised professional for completing this report refers to any of the following:

(i) a doctor;
(ii) a social worker;
(iii) a refuge or crisis worker;
(iv) a domestic and family violence support worker or case manager;
(v) an Aboriginal and Torres Strait Islander medical service;
(vi) a solicitor.

A tenant/resident can choose to either show or give a copy of this completed report to their manager/provider alongside a completed Domestic and Family Violence Notice ending tenancy/residency.


Everyone deserves to feel safe at home – domestic and family violence is never acceptable.

Help and support is available. Learn more.

    Form - Domestic and Family Violence Report
    Download(PDF 75KB)
    Current version: v5 Jun21
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