External referral form

Organisation Name: *

Contact Person: *

Position/Role:

Phone:

Email Address: *

Date of Referral: *

Full Name: *

Date of Birth: *

Gender/Pronouns:

Address (or location known):

Phone/Preferred Contact: *

Interpreter Required: Yes No

If yes? Language:

List children (if applicable, Name and DOB):

Reason for Referral/Support Needs: Homelessness or at risk of homelessness Financial hardship Safety concerns (incl. family or domestic violence) Mental health or wellbeing Social isolation / community connection Other

Brief description of presenting situation:

Current Supports/Services Involved: Case Managers Housing providers Medical or community services Other

Income/Employment/Financial difficulties:

Urgency/Risk Indicators:: Immediate safety risk No safe accommodation tonight Vulnerable child/young person involved Complex needs requiring coordinated response Other

Preferred Contact Method for Follow-Up: * Client to be contacted directly Referrer to be contacted for coordination Joint call / meeting requested

Consent: * I have obtained the client’s consent to share this information with The Salvation Army – FIRST Canberra for the purposes of referral, triage, and connection to supports.