External Agencies - HEF Application

Date *

Referring organisation *

Referring Worker *

Referring worker email address *

Referring worker phone number *

BeyondHousing office email *

e.g. shepparton@beyondhousing.org.au or wangaratta@beyondhousing.org.au

Client Details

Name *

Date of Birth *

Gender *

Phone Number

Indigenous status *

CALD *

IF CALD, Country of Birth *

If CALD, Year of Arrival

Main Income Source *

Last paid date *

Proof of income *

Centrelink (upload income statement)Payslip (upload payslip)Nil income

Upload Payslip/Centrelink income statement/MARAM *

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Tick to add Client 2

Client 2 Name *

Client 2 Date of Birth *

Client 2 Gender *

Client 2 - Phone Number

Client 2 Indigenous status *

Client 2 CALD *

Client 2 If CALD, Country of Birth

Client 2 If CALD, Year of Arrival

Client 2 - Main Income Source *

Client 2 - Last paid date *

Client 2 - Proof of income *

Centrelink (upload income statement)Payslip (upload payslip)Nil income

Client 2 - Upload payslip/centrelink income/MARAM

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Does the client have children?

YesNo

How many children?

Children

Name - Child 1

Date of Birth - Child 1

Gender - Child 1

Tick to add Child 2

Name - Child 2

Date of Birth - Child 2

Gender - Child 2

Tick to add Child 3

Name - Child 3

Date of Birth - Child 3

Gender - Child 3

Tick to add Child 4

Name - Child 4

Date of Birth - Child 4

Gender - Child 4

If more than 4 children, add names, date of birth and gender here

Support Period Details

Main presenting reason *

NDIS Package *

Does the client need help/supervision with any of the following *

Self careMobility CommunicationNot applicable

Other mental health indicators *

Prior mental health diagnosis *

How long have services been received *

Living Arrangements *

Dwelling *

Tenure *

Conditions of occupancy *

Labour force status *

Employment status *

Awaiting benefit *

Student or trainee *

Enrolled in *

School enrolment *

Child protection order *

Accommodation Details

Accommodation Provider *

Has accommodation booking been confirmed? *

Check in date *

Check out date *

Amount Requested *

Number of Nights *

Clients exit plan once accommodation ends *

Declaration

Consent type *

VerbalWritten

I / We confirm: *

The information provided is true and correct. The information provided will be forwarded to BeyondHousing for the purpose of providing financial assistance. BeyondHousing will contact me on the next business day to assist with ongoing housing needs. I give permission for BeyondHousing to contact my worker to discuss this financial assistance in further detail.

I have discussed the below with the client, and the client has provided verbal consent for: *

The information to be forwarded to BeyondHousing for the purpose of providing financial assistance. BeyondHousing to make contact with the client on the next business day to assist with ongoing housing needs. BeyondHousing to contact the client's support worker to discuss this financial assistance in further detail.

Signature - Person 1 *

Draw signature|Type signatureClear

Signature - Person 2 *

Draw signature|Type signatureClear

Date - Person 1 *

Date - Person 2 *

BeyondHousing only

Initial Assessment and Planning Worker assigned to review *

Date

External HEF request approved

YesNo

Reason not approved

HEF entered in Client Management System

HEF entered on commitment sheet

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