Crisis AccommodationReferral Form

Procedure

  • Please fill out this form and send it to
  • You are required to read and accept the conditions set out in this referral form before you complete it. By signing this form, it is assumed you have understood and accepted the contents of this form.
  • This form also needs to be signed off by a Manager from the referral party responsible for the program before it is submitted to SSI.
  • Requests received during business hours (9.00am-5.00pm) will be processed on the same day.
  • Requests made by SSI Staff - For any urgent accommodation needs outside business hours, please call the SSI emergency number 1800-774-142.

Client profile
Family name / Given names
Boat/Client ID / Contact number
Gender / ☐ Female ☐ Male / Age & Date of birth
Country of birth / Year arrived in Australia
Marital status / Language spoken
Religion / Interpreter required / ☐ Yes ☐ No
Employed / ☐ Yes ☐ No / Level of education

N.B.Please include the details of other family members in the area provided at the end of this form.

Immediate safety concerns
Do you have safety concerns for the client? / ☐ Yes ☐ No
<Insert details>
Client suitable to accommodate under shared arrangement? / ☐ Yes ☐ No
<Insert details>
Health and other concerns
☐ Physical health / ☐Mental health / ☐Domestic or family violence
☐Threats, violence or harassment / ☐Suicidal thoughts/self-harm / ☐Other
<Insert details>
Special requirements / <Insert details>
Reason for request / <Insert details>
Duration / <Insert details>
Rent payments
Rent will be paid by / ☐Referring organisation ☐By Client
☐Split payment between Client & referral organisation
If rent is to be paid by the client, please provide client account details
Account name / Bank name
Account number / BSB number
Accommodation terms
By sending this form, the referringorganisation and the client agree that:
  • Weekly rent includes utilities (water, gas and electricity only).
  • There are no door locks for the bedrooms.
  • Single clients must be willing to share a room under shared accommodation arrangement.
  • Neither SSI nor the housing provider (e.g. serviced apartment or property owners) are liable for any loss or damage to the client’s belongings. Clients should be responsible to safeguard their personal belongings.
  • Clients should take all their belongings with them at the time of vacating the property.
  • Subject to the rental payment arrangements indicated in this form, clients and/or the referring organisation (as applicable)mustpay rent for the accommodation every two weeks (in advance), until the day property keys are returned back to SSI.
  • Clients are liable to pay for any damage to property or household items caused by them during their stay at the accommodation.In the event the client refuses to pay the rental arrears or property damages, the referring party agrees to pay them.
  • The referring party has to notify EHA staff as soon as they cease services to their client in EHA accommodation. Any rental arrears incurred as a result of the failure to notify has to be paid by the referring party. This also includes any property damages that have been caused by the client during the stay in the EHA accommodation.
  • Clients may be requested to relocate to a different property/location with 24 hours of notice. (This information is relevant mainly for clients accommodated under shared accommodation arrangements.)
  • Clients are not allowed to bring/store bulky items at crisis accommodation properties, i.e. furniture, whitegoods, etc.
  • The referring organisation should provide the casework support for clients throughout their stay at the crisis accommodation including exit plans.
  • If the client needs to extend the crisis accommodation arrangement, the client's case work staff should send an extension request at least one week prior to the end of existing accommodation arrangement. An extension request may be approved subject to the availability of a suitable property.
  • The completed referral form must be sent to ong with the copies of the documents below:
  • Photo ID documents for all adult clients
  • Recent bank statements and confirmation of next Centrelink payment dates for clients who will be paying the rent.
  • Subject to the rental payment arrangements indicated in this form, during the next business day of arrival, the client must be available between 9.00am to 3.00pm to set up a direct debit agreement with SSI for rental payments and complete the property check-in process.
  • Accommodation services are provided up to a maximum of six weeks only (unless approved by SSI Housing Division).
  • Clients should be aware that SSI Housing staff will regularly access the properties in order to facilitate check-in and check-out process for other clients sharing the accommodation facilities and also to perform routine checks.
  • Should there be any issues or disputes arise due to non-compliance behaviour of the occupants, the referring organisation will take all reasonable steps and actions to settle the matter.

By completing and returning this form by email (whether the form has been signed or not), you acknowledge and confirm the following:

  • the above accommodation terms have been explained to the client;
  • the client understands and accepts the accommodation terms; and
  • in your capacity as the referring organisation, you understand and accept the accommodation terms (as applicable).

Crisis Accommodation requested by
Name / Date
Position / Phone(s)
Organisation / ☐SSI ☐Other / Details
Signature of referring party / Signature of client
Signature of Responsible Manager from referring party

Please fill out this form and send to , attaching relevant documents.

Other family members
Family Name / Given Names
Boat/Client ID / Contact Number
Gender / ☐ Female ☐ Male / Date of Birth
Family Name / Given Names
Boat/Client ID / Contact Number
Gender / ☐ Female ☐ Male / Date of Birth
Family Name / Given Names
Boat/Client ID / Contact Number
Gender / ☐ Female ☐ Male / Date of Birth
Family Name / Given Names
Boat/Client ID / Contact Number
Gender / ☐ Female ☐ Male / Date of Birth
Family Name / Given Names
Boat/Client ID / Contact Number
Gender / ☐ Female ☐ Male / Date of Birth
Family Name / Given Names
Boat/Client ID / Contact Number
Gender / ☐ Female ☐ Male / Date of Birth
Family Name / Given Names
Boat/Client ID / Contact Number
Gender / ☐ Female ☐ Male / Date of Birth
Family Name / Given Names
Boat/Client ID / Contact Number
Gender / ☐ Female ☐ Male / Date of Birth
Family Name / Given Names
Boat/Client ID / Contact Number
Gender / ☐ Female ☐ Male / Date of Birth
Family Name / Given Names
Boat/Client ID / Contact Number
Gender / ☐ Female ☐ Male / Date of Birth

Please send the documents listed below along with referral form:

  • Copy of photo ID documents for all clients above 18 years of age
  • Copy of the bank statement of the principal applicant

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