Referral form

REFERRING PERSON/ORGANISATION DETAILS

Name of person referring*:
Organisation:
Email*:
Telephone*:

CLIENT FOR REFERRAL

Client name*:
Date of birth:
Address:
Telephone*:

SHS Eligibility (Client must be homeless OR at risk of homelessness to meet SHS guidelines)

Is the person homeless?*
YesNo

OR At risk of homelessness?*
YesNo

Family Details

Partner's name:
Partner's telephone:
Child details (names and dates of birth):

Are there any worker safety issues or family violence?*
YesNo

If yes, please explain:

Reason for referral:

Cultural information

Does the client identify as Aboriginal/Torres Strait Islander?
YesNo

Does the client's partner identify as Aboriginal/Torres Strait Islander?
YesNo

Do the children identify as Aboriginal/Torres Strait Islander?
YesNo

Is the client/partner/child from a CALD background?
YesNo

If yes, what is their cultural background?

Are there any worker safety issues with this family and/or worker?*
YesNo

If yes, please explain:

Is the client aware that a referral has been made to Gunnedah Family Support?*
YesNo

Please describe the services required for this client:
For example, homeless or at risk of homelessness, domestic violence, group work, early intervention family work, parenting programs and outreach playgroups

What other services are currently working with this client?

Any other information that may be relevant: