Referral	Form	SHS 01

(Specialist Homelessness Services)

Client Details
Surname *:	Given Name *:
Gender *:	Female Male	DOB *:	Phone *:
Address *:
(Number and Street)
Suburb *:	Post Code *:
Language Spoken at Home (If NOT English) *:
Does the client require interpreter *:	Yes No
Is the client of Aboriginal or Torres Strait Islander origin *:	Yes No
If Yes,	Aboriginal	Torres Strait Islander	Both Aboriginal and Torres Strait Islander
Name of Guardian (If under 18) *:	Phone *:
Address:

Referring Agency Details
Agency *:
Contact Person *:	Position:
Address *:
Phone *:	Email *:
Please indicate what type of support you are seeking
Support to Sustain Current Tenancies	Housing and Accommodation Support
Assistance to Find / Secure New Housing	Outreach and Advocacy with Centrelink & Housing NSW

Reason for Referral (Please give as much information as possible)

Additional Information
Past Accommodation Services / Housing Situations
Safety (Incl DV, threats, violence or harassment, suicidal thoughts / self-harm, AVOs)
Drug or Alcohol Issues
Disabilities / Health / Mental Health Issues
Family Issues
History of legal involvement
Other Significant Support / People / Services & Contact Information
Other

Referrer’s Declaration
By signing this Referral Form, I have obtained consent, either in verbal or written format, from the client detailed above to release all information contained in this Referral Form to the Accessible Diversity Services Initiative Limited (ADSI).
Referrer Name *: (Please Print)	Referrer Signature *:
Date *:

Please send the completed referral via	Office Use Only
Email: housing@adsi.org.au (Preferred), or Fax: 02 8737 5599	Date Received:
Date Assessed:
Assessment Outcome:	Eligible Not Eligible
Referral Allocated To: