This form is for tenants, potential tenants or workers enquiring about support for a tenancy at risk (Tenancy Support) or advice to find a new tenancy (Tenancy Options). Complete relevant parts of the form, depending on whether seeking Tenancy Support or Tenancy Options or both.

Send the completed form to , and call 02 6207 2427 if any questions.

All information provided will be kept in accordance with the STS Privacy Statement. This covers collection and use of information, protection of personal information and access to personal information. We value a client’s privacy and will only share information with other services that the client has agreed to or there is an imminent threat to an individuals or public welfare, safety or required by the law.

Enquiry date: _ _ / _ _ / 201_

Complete this first section only if referral via agency or organisation

Worker: / Organisation:
Phone: / Email:
Has the tenant given consent for this enquiry to STS? Yes / No

Complete following sections for all referrals

Name: / Date of birth:
Contact phone(s): / Email:
Address:
Alternate contact person/phone (if applicable):
Preferred contact method:
Does the tenant identify as Aboriginal or Torres Strait Islander:
Aboriginal / Both
Torres Strait Islander / Neither
Country of birth: / Year of arrival:
Language spoken at home: / Interpreter needed? Yes / No

Household details

Number of adults:
Number and ages of children: / 0 – 2 years / 9 – 12 years
3 – 5 years / 13 – 14 years
6 – 8 years / 15 – 17 years
Any conditions that STS should be aware of:
Eg. Mental or Physical Health or Disability
Details:
Other agencies involved with household:
Is anyone receiving or potentially eligible for an NDIS package?
Receiving / May be eligible / No

Current tenancy

Public Housing
/ Private Rental
Community Housing
/ Share Housing
Friends or Family
/ Couch surfing or No tenancy
Other: (explain)
Current rental type: Fixed / Periodic
Current rental payment $ / Week / Fortnight / Month
Is the current tenancy expected to end soon? / Yes / No
If yes, provide details (how soon, notices or legal action involved):

Income / Savings

Centrelink / Employment/other income
Disability Support (DSP) / Full time employment
Newstart / Youth Allowance
/ Part time employment
ABStudyAustudy
/ Casual employment
Family Tax Benefit A/B
/ Other income: (please specify)
Aged Pension
Other benefit (please specify)
Total $
per week / fortnight / Total $
per week / fortnight / month
Commonwealth Rent Assistance $
per week / fortnight / Savings $
Child Support Receiving $ / per week / fortnight / month
Child Support Paying $ / per week / fortnight / month
Debt / Loans / Yes / No
If Yes approximate amount $
Type
Rental Arrears(Housing ACT / Private) / Bank / Payday Loans
Housing ACT – bond loan
/ Centrelink
Housing ACT - Other
/ Credit / Store Cards
Other, including utilities: (please specify)

What type of support is needed?

Tenancy Support (to sustain a tenancy) / Complete page 3
Tenancy Options (to find a new tenancy) / Complete page 4
Both / Complete both pages

Referral to Tenancy Support (to sustain a tenancy)

What are the reasons the tenancy is at risk?
What assistance is needed from Tenancy Support?
Any other information relevant for Tenancy Support (including any other issues or risks)?
Priority assessment:
A / B / C / D / E
High risk to tenancy
At immediate risk or tenancy issues present immediate risk to safety or welfare
AND
High tenancy support need
No or inadequate supports in place / High risk to tenancy andmedium support need
Have some supports in place but tenancy specific support would assist
OR
High tenancy support need andmedium risk to tenancy
Tenancy issues present that may place tenancy at risk, or tenancy issues present some concerns for safety or welfare / Medium risk to tenancy and medium tenancy support need / Medium risk to tenancy and Low support need / Low risk to tenancy
Would seek to take on requests under Priority A and B at next allocation meeting (or sooner if very urgent), take on Priority C within two to three weeks, for Priority D and E would seek to provide information and refer to other services.
Note: STS will seek to provide a timely response for everyone contacting the service, regardless of the priority. Allocations will take into account time waiting for support as well as priority.

Referral to Tenancy Options (to find a tenancy)

Tenancy Options provides information about tenancy options and advice on how to secure a tenancy, other than public housing. Thus, Tenancy Options is for people who:

  • are open to looking at options other than public housing
  • are able to search and apply for a tenancy (with assistance from another service if needed)
  • have access to income adequate to sustain community or private rental

Note: The amount of income needed will vary depending on circumstances – Tenancy Options can provide advice on this, but to be able to assist a person to secure a tenancy the person must have access to some regular income.

Expectations

Is the person open to looking at options other than public housing? / Yes / No

Timeframe: Given the high demand, it may be a week or two before a Tenancy Options team member can make contact, but they will prioritise based on urgency. The team can provide information on expected waiting timeson request.

Specific household requirements

Any pets? / Yes / No
If Yes provide details:
Any special requirements
(e.g. no stairs, wheelchair accessible) / Yes / No
If Yes provide details:

Possible barriers

What possible barriers might the household may face in securing a tenancy?

1