Shelter Referral Form

Who is completing this form? *

I am the person applying for a bed

I am referring someone else

Referrer Full Name *

Organisation / Practice Name *

Role / Title *

Referrer Contact Number *

Referrer Email *

Relationship to Applicant *

e.g. Case Worker, Outreach Nurse, Family Member, Friend, etc.

Applicant Full Name *

Date of birth *

Gender *

Phone Number *

Email *

Address

Street Address

City *

State *

What type of room would you be comfortable with? *

I am happy to share a room with one other person

I would prefer a single room only

I can share if needed, but prefer a single room if available

Please note that single rooms are limited and may result in a longer wait. Do you still wish to be considered only for a single room? *

Yes, only single room

I’m open to sharing if needed

Are you over 25 years old? *

Yes

Note: Unfortunately, we can only accept applicants over 25. Please seek alternative services such as YFS 07 3826 1500.

Do you have children in your care? *

Yes

Note: Unfortunately, we are not able to accommodate families. Please seek alternative services through the Homeless Hotline 1800 47 47 33 or YFS 07 3826 1500.

Do you currently have any mental health concerns? *

Yes

Please provide details (diagnosis, recent episodes, medications, etc.): *

Do you have any physical health issues? *

Yes

Please provide details (condition, treatment, any support needed) *

Are you currently experiencing any addictions (e.g., drugs, alcohol, gambling, tobacco)? *

Yes

When was the last use? *

What substances or behaviours are involved? *

Please describe the addiction(s) and any treatment or support you’re receiving: *

Do you have a history of violence? *

Yes

Please provide details, including any incidents or patterns we should know about: *

Do you have a history of sexual offences? *

Yes

Please provide details (charges, dates, outcomes, if applicable): *

Are you currently experiencing domestic or family violence (as a victim or perpetrator)? *

Yes

Please provide context, including whether it is ongoing and any support you have *

Is there anything else we should know about your situation? *

How much can you contribute initially toward accommodation? *

Will ongoing payment of rent be a challenge? *

Yes

Next Centrelink or payment date: *

Do you consent to a criminal history check? *

Yes

Do you require a rehabilitation recovery program for drug or alcohol addiction? *

Yes

Unsure

Do you have a support coordinator or NDIS company involved? *

Yes

Name of NDIS Company *

Contact Person (optional)

NDIS Number (if known)

Are you on parole/probation/bail? *

Yes

Do you have any upcoming court dates? *

Is there anything else you’d like us to know to support your referral or application? *

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