(Insert Site Name) Community Support Services

SAMIS
Code:
Date Visit:
Date Entered
SAMIS: / Entered
By:

(Insert Site Name) .. Community Support Services.

Emergency Relief - Client Assistance Form.

Personal Details:

First Name: …………………………………..Surname: …………………………………………………

Date of Birth:…………………………………..

Change in Client Details:

Have any of your Personal/Demographic details changed since last visit to this site?

Yes: 1. Registration “Update”Form completed.√ By: (Name)

2.Registration in SAMIS Updated: √ By: (Name)

No: No action required.

Assistance: Financial and Material Aid:

(Includes: Food parcels/vouchers – Material Goods – Health care – Transport – Utilities Bills – Rent/Mortgage

(Ref. DSS Service Type Matrix)

Assistance Type: / Voucher/Gift Card No.
Impress Card (Receipt No). Cheque No. / Additional Information
(if required) / Amount: / Entered in SAMIS
√
√
√
√
√
Total Assistance:
(Total Assistance MUST be calculated and recorded) / $

I confirm that I have received the Assistance as detailed above.

Recipient (Client) Signature:……………………………………………………………………………

Worker’s Name:……………………………..Worker’s Signature: …….………………………

Corps Officer/Manager Approval required: Yes/No.

Corps Officer / Manager Signature:……………………………………………

Additional Assistance (ER Intensive Assistance):

Advocacy/Liaison / SAMIS Entry
Example:Advocacy support - Utilities Provider - Centrelink – Landlord / √
Information / Advice / Referral / SAMIS Entry
Example: Information/Advice: Support with Forms / √
Referral Details:
Example:Financial Counselling / Case Management / AOD / Housing / Health Services/Education
Referral to Internal Services (TSA) / Referral to External Services / Referral Form / SAMIS Entry
. / √ / √
√ / √
Education / Skills Training / SAMIS Entry
Example: Delivery of Basic Budget skills - IT/Computer Literacy Skills - General Literacy Skills / √
Community Capacity Building
Example: Mens’ Shed - Mothers Groups – Mainly Music – Play Group – Community Gardens
Referral Details: / SAMIS Entry
Referral to Internal Services (TSA) / Referral to External Services / Referral Form√ / √
Unmet Need: / Referral Recorded / SAMIS Entry
Assistance requested / Could Not Provide (Select Reason)
A.No resources. (unmet need) / √
B.No resources – Referral Made / √
C.Outside Scope of ER (unmet need) / √
D.Outside Scope of ER - Referral Made. / √

Territorial Social Program Department (AUS) – Client Assistance Form Version 1.16 Date: March, 2016 Page 1