Emergency Relief - Client Registration Form

SAMIS
Code: / SAMIS
Intake/Assessment
Recorded: √
Date Visit:
Date Entered
SAMIS: / Entered
By:

(Insert Site Name) Community Support Services.

Emergency Relief - Client Registration Form.

PERSONAL DETAILS:

First name: ______Surname: ______

Address: ______

Suburb: ______Postcode:______

Date of birth: ______Phone:______Mobile: ______

Email Address: ______

ATSI: Neither Aboriginal Torres Strait Islander Both

Country of Birth: ______Year of Arrival in Australia: ______

Residency Status:______Ethnicity: ______

Main Language Spoken at Home: ______

Privacy Consent - Important

By signing this document and accessing assistance from The Salvation Army, I acknowledge

that I have been provided with a copy of The Salvation Army Privacy Notice;
that I have read and understood the Privacy Notice and freely agree to provide the sensitive information referred to and/or contained in this document to The Salvation Army;
that the information I have provided to The Salvation Army is current and I consent to the disclosure of this information to the types of organisations or individuals identified in the Privacy Notice;
that I undertake to notify The Salvation Army as soon as practicable if this information is no longer current or if my consent for the collection of this information is withdrawn;
that until such time that I notify The Salvation Army that my consent is withdrawn, I agree that The Salvation Army will be entitled to presume that this consent is current and informed.

Signature of Client ______Print Name ______Date ______

PERSONAL DETAILS (Cont’d):

Dependents residing at your current address:

First name/Surname Sex DOB Relationship Country of Birth

______M / F ______

Demographic and Other Information:

Income Source: / Living Situation
DSP / Youth Allowance / House/Flat Public / House/Flat Owned
Newstart / Family Tax Benefit A / House/Flat Rent / Transitional Housing
Aged Pension / Carers Allowance / Hotel/Motel/Hostel / Boarding / Rooming
Austudy / Parenting Payment / Rough (outdoors) / Crisis Housing
No Income / Wages / Salary / Improvised (Couch / Improvised (Car)
Other:
Disability - as stated by client: / Income Management: / Yes / No
None Identified / Psychiatric / DSS Research: / Yes / No
Intellectual Learning / Physical/Diverse / Information Not collected:
Sensory/Speech / Not stated/inadequately described / Client left without providing information. / Client declined to provide information.

Territorial Social Program Department (AUS) – Client Registration Form - Version 1.16 - March, 2016 Page 1