Referral to Beyond Housing

Referral details

Date *

Referring worker

Referring service *

If your organisation name does not appear, choose other and type the name in the text box provided.

If referring service is other, please describe *

Referring worker email address *

Referring worker phone number *

Has the renter engaged with your service *

YesNo

Referral category *

Establishing Successful TenanciesIntervention at Risk TenanciesAdvocacy

Endorser's email address *

Referral to

BeyondHousing office email *

e.g. shepparton@beyondhousing.org.au. seymour@beyondhousing.org.au, wodonga@beyondhousing.org.au. wangaratta@beyondhousing.org.au

Referring to which BeyondHousing program *

Options: ITAR, Tenancy Plus, STAR

Will a copy of this referral be emailed to the client? *

YesNo

Consent & Safety

Has the renter's consent to refer been obtained *

Yes - written consentYes - verbal consentNo - duty of care referral

Is it safe for BeyondHousing to make contact with the client via phone, on receipt of this referral? *

YesNo

When is it safe to call?

If unsafe to call, detail alternative contact options

Upload a copy of the written consent

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Primary renter information

First name *

Surname *

Gender *

Gender Options: Female, Male, Other, Prefer not to say

Date of birth *

Age

Main income source *

Mobile/phone number *must contain 10 characters

Email

Indigenous status *

Options: Neither, Aboriginal, Torres Strait Islander, Both Aboriginal and Torres Strait Islander

Address *

CALD *

Country of birth *

Preferred language *

Interpreter required *

YesNo

Female interpreter required *

YesNo

Additional household members

Tick to add Household member 1

Name *

Date of Birth *

Age

Gender *

Gender Options: Female, Male, Other, Prefer not to say

Relationship *

Indigenous/CALD *

Email address

Phone number

Tick to add Household member 2

Name *

Date of Birth *

Age

Gender *

Relationship *

Indigenous/CALD *

Tick to add Household member 3

Name *

Date of Birth *

Age

Gender *

Relationship *

Indigenous/CALD *

Tick to Add Household member 4

Name *

Date of Birth *

Age

Gender *

Relationship *

Indigenous/CALD *

Tick to add Houshold member 5

Name *

Date of Birth *

Age

Gender *

Relationship *

Indigenous/CALD *

Tick to add Houshold member 6

Name *

Date of Birth *

Age

Gender *

Relationship *

Indigenous/CALD *

Is the renter or a household member pregnant *

YesNo

Estimated due date *

Current tenancy information

Rental Provider name *

Tenancy Reference Number (if applicable)

Property Manager/Housing Services Officer name *

Phone number *

Tenancy start date *Use approximate if unknown

Current weekly rent ($) *

Account balance ($) *

Account balance *

Credit Debit

Is the renter 14 days in arrears *

YesNo

Legal action pending *

YesNo

If yes, what action *

VCAT hearing pending *

YesNo

Date and time of VCAT hearing

Last home visit *

Last contact *

Is the renter in crisis and at imminent risk of losing their tenancy *

YesNo

Attach supporting documentation e.g. Notice to Vacate, Breach *

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Has the renter exited from Tenancy Plus/ITAR within the last 6 months and are re-referring *

YesNo

Summary of current tenancy concerns *

Financial

Income source, including realisable assets, for example; Centrelink, wages, investment

Centrelink ($)

Gross wages ($)

Investments - Gross interest/earnings ($)

Other ($)

Frequency *

WeeklyFortnightly

Previous tenancy charges

Rental arrears ($)

Maintenance arrears ($)

DFFH Bond loan/s outstanding ($)

Oustanding debts if known

Centrelink ($)

Electricity ($)

Bank ($)

Other ($)

If Other ($), describe creditor

Identified risk and support needs

Assistance being sought in relation to this tenancy *

Current and previous support provider/s

Current support provider *

YesNo

Organisation

Case manager name

Contact details

Tick to add current support provider

Organisation

Case manager name

Contact details

Previous support provider *

YesNo

Organisation

Case manager name

Contact details

Please attach client support plan/s if available

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Personal supports contact details

Support type

Family memberFriend/carerCommunity support

Name/Organisation

Phone number

Email

Background, case notes for referral

(If this referral is being made under duty of care, please note why and how you have attempted to contact the renter to gain consent)

Background for referral *

Duty of Care: One of the objectives of the Housing Act 1983 (Vic) is to promote security and a variety of tenure for all tenants and information to be disclosed pursuant to Information Privacy Principles. Principle 2.1 (d) – the organisation reasonably believes that the use of disclosure is necessary to lessen or prevent serious (and imminent) threat to an individual’s life or their (or the public’s), health, safety or welfare. Therefore for the purpose of a referral this section allows for the disclosure of tenant information without prior consent and without breaching the Information Privacy Principles.

Managers endorsement (Tenancy Plus only)

Manager endorses referral *

YesNo

Date *

Manager's name *

Manager's signature *

Draw signature|Type signatureClear

BeyondHousing only

Assigned to BeyondHousing staff member (email) *

Assigned by (email) *

Date assigned *

Referral outcome

Further information required to assess the referral *

YesNo

Date *

Please detail additional information required *

Referral accepted *

YesNoWaitlist

Reason for non-acceptance *

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