Agency referral form | The Salvation Army Australia

Referring Organisation Details

Organisation Name

Contact Person

Position/Role

Phone

Email Address

Date of Referral

Client Details

Full Name

Date of Birth

Gender/Pronouns

LQBTIQA+ identity

Do you identify as Aboriginal or Torres Strait Islander?

Yes

Prefer not to say

Country of Birth

Year of arrival

Address (or location known)

Phone/Preferred Contact

Main Language spoken at home

Other language spoken at home

Interpreter Required

Yes

Interpreter language

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

Details of situation

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)

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

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

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.

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External referral form

Referring Organisation Details

Client Details

Details of situation