Please wait... Name of referring outreach service worker Email address of referring outreach service worker Local Area Health Network Contact Number Suburb client is calling from Date of Referral Main applicant's details Title Last name or family name Given name(s) Sex MaleFemaleOtherUnknown Unit/House number Street/Avenue Town or Suburb Postcode Date of Birth Country of Birth Aboriginal or Torres Strait Islander descent? YesNoUnknown Main Language If an interpreter is required, what language? Current citizenship status Australian citizen Permanent resident Sponsored migrant New Zealand Special Category Visa Refugee / humanitarian Asylum seeker Other Visa subclass (if applicable) Date of arrival in Australia Phone Mobile Email Centrelink Reference Number (if applicable) Income and Assets Type of income Paid Amount WeeklyFortnightlyMonthly WeeklyFortnightlyMonthly WeeklyFortnightlyMonthly WeeklyFortnightlyMonthly Type of financial asset Amount Income Confirmation Scheme Consent Authority Does the client authorise DCJ to use Centrelink Confirmation eServices? Yes No This consent will be used for the sole purpose of authorising Centrelink to provide information to DCJ Housing to assess your eligibility for our services. If you do not allow Centrelink to provide your information to us electronically, you will need to obtain this information from Centrelink yourself and provide it to us. Other household members details Family name Given name(s) Date of birth Sex Relationship to main Male Female Other Unknown Male Female Other Unknown Male Female Other Unknown Male Female Other Unknown Male Female Other Unknown Male Female Other Unknown Name of additional person Type of financial asset Amount Assessment Questions 1. Has there been a Specialist Homelessness Services (SHS) assessment in the last 24 hours? Yes - go to 1a No - go to 2 2. Does the client have somewhere safe to stay tonight? Yes - go to 2a No - go to 3 3. Why can the client not continue in the current accommodation? Official notification - go to 3a Financial difficulties - go to 3b Family and Domestic issues - go to 3c Property issues - go to 3d 4. How long has the client been homeless? LESS1W - Less than a week 2TO3W - 2-3 weeks 3TO4W - 3-4 weeks 1TO3M - 1-3 months 3TO6M - 3-6 months 6TO9M - 6-9 months 9TO12M - 9-12 months 1TO2Y - 1-2 years 2TO3Y - 2-3 years 3TO5Y - 3-5 years MORE5Y - Less than a week 5. Has the client been homeless within the last five years? Yes - go to 5a No - go to 6 6. Does the client have Mental Health issues? Yes No 7. Does the client have Drug and Alcohol issues? Yes No 8. Does the client have a permanent disability or medical condition? Yes No 9. What support does the client need to live independently? NONE - None MENTAL - Mental Health DRUG - Drug and Alcohol DISAB - Disability FINANCE - Financial OTHER - Other 10. Has the client previously been assisted by an SHS service? Yes No 11. Are there any restrictions or barriers to where the client can live? Yes - go to 11a No - go to 12 12. Is the client, or anyone listed, barred from any service, have a history of difficult behaviour or is there any other reason that would limit access to some types of assistance? Yes - go to 12a No - go to 13 13. In the last 2 years, has the client rented anywhere for at least 6 months? Yes No 14. Does the client give consent to provide information to other government and/or non-government agencies? Yes No 15. Were there any indicators that the client may be a risk to themselves or others? Yes No 16. Has a Mandatory Reporter Guide (MRG) tool been completed? Yes No 17. Has a report been forwarded to Department of Communities and Justice - Community Services? Yes No 18. Does the client have support needs? NO LOW MEDIUM HIGH Additional information