Ph076 Form - Housing Assistance Referral Form printable pdf download

Ph076 Form - Housing Assistance Referral Form

Housing Assistance Referral

Form

For use by referring agencies, domiciliary/community nurses, occupational therapists,

physiotherapists, social workers, psychologists or other support workers. Completion of this

form will assist in the assessment of the client’s application for housing assistance. The

personal information provided in this form will be kept confidential and not be disclosed to

any unauthorised person.

Applicant’s details

Full name

Date of birth

Is there any information in this report which, if released to the applicant, might be

prejudicial to his/her physical or mental health?

Yes

If ‘Yes’, please identify the information and state why this should not be released to the

client

How long has this person been under your care?

Please provide a brief description of the assistance/service you provide to the applicant.

Where is the applicant living now?

Have you seen the property where the applicant is living now?

Yes

If ‘Yes’, when was the last time that you saw it?

How long has the applicant been living in the present housing?

Are you aware of any problems the applicant has with continuing to live in their current

housing?

Note - if ‘yes’, please provide details below.

Yes

In your opinion are the features of the current housing restricting this person from

undertaking essential activities of daily living (self care - bathing, grooming, and

mobility).

Note - if ‘yes’, please provide details below.

Yes

Department of Housing and Public Works

PH076 (28/10/2014) Page 1

Ph076 Form - Housing Assistance Referral Form