External referral form

Organisation Name: *

Contact Person: *

Position/Role:

Phone:

Email Address: *

Date of Referral: *

Full Name: *

Date of Birth: *

Gender/Pronouns:

LQBTIQA+ identity:

Do you identify as Aboriginal or Torres Strait Islander?: * Yes No Prefer not to say

Country of Birth (if this is not Australia, please include year of arrival): *

Address (or location known):

Phone/Preferred Contact: *

Main Language spoken at home:

Other language spoken at home:

Interpreter Required: Yes No

If yes? Language:

List children (if applicable, Name, Gender and DOB):

Are you a current Housing ACT applicant and/or tenant? Please specify: *

Please outline details of your current housing situation (couch surfing, private/public tenant, sleeping rough etc): *

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

Please outline details of the issue and needs including the referral pathways sought through FIRST Canberra: *

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

Type of household income (Centrelink, employment etc). Please detail type of Centrelink payments if applicable and any information or concerns about the household’s financial situation: *

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.