SDA Referral - Abilities Housing Services

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SDA Referral

Specialist Disability Accommodation (SDA) Referral Form

Please complete all sections. Incomplete referrals will not be accepted. We’ll get back to you as soon as possible.

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- Step 1 of 7

Referrer Details

Name *

Agency/Position *

Postal Address

Postcode *

Phone *

Email *

How did you hear about us?

Website
Social Media
Event
Friend/Family/Another Client
Radio
Google
Flyer
Advertising
Other

Please provide details

Applicant to Complete

First Name *

Last Name *

Preferred Name

Date of Birth *

Address *

Postcode *

Phone *

Email *

Gender *

Female
Male
Transgender Female (MTF)
Transgender Male (FTM)
Non-Binary
Prefer not to disclose
Different Identity

Please provide details *

Sexuality

Straight/Heterosexual
Lesbian/Gay/Homosexual
Bisexual
Unsure
Prefer not to disclose
Self describe

Please provide details

Intersex Status

Yes
No
Unsure
Prefer not to disclose

Applicant to Complete

Pronouns

She/Her/Hers
He/Him/His
They/Them/Theirs
My Name/None
Other

Please provide details

Relationship Status *

Single
Married
Separated
Divorced
Widowed
Defacto
Self describe

Please provide details *

Aboriginal *

Yes
No

Torres Strait Origin *

Yes
No

Ethnicity *

Country of Birth *

Culturally & Linguistically Diverse *

Yes
No

Main Language Spoken *

English
Other

Please provide details *

Interpreter Required *

Yes
No

Children

Yes
No

Source of Income *

Age Pension
Carer's Allowance
Disability Pension
Paid Work
Youth Allowance
Department of Veteran's Affairs
Unemployment (Newstart)
Other

Please provide details *

Living *

Living Independently
Living with Family Member/Carer
Other

Please provide details *

Hold a DVA Card?

Yes
No

If Yes, what type?

Gold
White
Other

Centrelink Number

Expiry

Medicare Number

Expiry

Private Health Cover

Yes
No

Provider

Member ID

Ambulance Cover

Yes
No

Are you currently receiving services from another program within Abilities Housing Services?

Yes
No

Contacts

Name *

Nominated support person (Next of Kin/Alternative Contact)

Phone

Mobile *

Email *

Relationship *

Do you have a case manager?

Yes
No

Name *

Organisation *

Phone

Mobile *

Email *

Do you have a guardian appointed?

Yes
No

Name *

Phone

Mobile *

Email *

Do you have a public trustee?

Yes
No

Name *

Phone

Mobile *

Email *

Do you have a GP?

Yes
No

Name *

Phone

Mobile *

Email *

Which of the above is your preferred contact? *

Support Person
Case Manager
Guardian Appointed
Public Trustee
GP

Preferred method of contact

Text
Phone call
Email
Mail
Other

Please provide details

Health and Wellbeing

Existing NDIS Plan? *

Yes
No

NDIS Plan Number *

Formal mental health diagnosis? *

Yes
No

If Yes, please provide details *

Drug and Alcohol Use

Alcohol *

None
Current Use
In Recovery
History of use

Please provide details *

T.H.C. (Cannabis) *

None
Current Use
In Recovery
History of use

Please provide details *

Benzodiazapines *

None
Current Use
In Recovery
History of use

Please provide details *

Opioids *

None
Current Use
In Recovery
History of use

Please provide details *

Stimulants *

None
Amphetamines
Dexamphetamines A

Please provide details *

Other *

None
Hallucinogens
MDMA - Ecstasy
Prescription Drugs
Solvents

Please provide details *

Cigarettes *

None
Current Use
In Recovery
History of use

Please provide details *

Any associated risk behaviours or problems? *

(Injecting, overdoses, Hepatitis status)

While I am a resident, if I am considered to be using drugs and alcohol which is impacting on my recovery, I agree to work with an appropriate Drug and Alcohol Service *

Agree
Disagree

If Disagree, please provide details *

Mental and Physical Health

Do you have any physical/health issues or disabilities? (tick all that apply and provide additional information below)

Diabetes *

Yes
No

Podiatry *

Yes
No

Bruise or bleed easily *

Yes
No

Dental *

Yes
No

Heart complaints *

Yes
No

Ulcerations *

Yes
No

Liver disease *

Yes
No

Asthma *

Yes
No

Epilepsy *

Yes
No

Allergies *

Yes
No

HIV/AIDS *

Yes
No

Allergic to medication *

Yes
No

Blood pressure *

Yes
No

Acquired head injury *

Yes
No

Speech *

Yes
No

Thyroid problems *

Yes
No

Visual *

Yes
No

Eating disorders *

Yes
No

Hearing *

Yes
No

Substance abuse *

Yes
No

Mobility impairments *

Yes
No

Women’s health screens *

Yes
No

Men’s health screens *

Yes
No

Respiratory disease *

Yes
No

Intersex variation *

Yes
No

Transgender health screens *

Yes
No

Other *

Yes
No

If Yes, please provide details *

Please provide additional information, include the impact on your life and relating support needs *

Do you have any mobility aids? *

Yes
No

If Yes, please provide details *

Do you take regular medication? *

Yes
No

Do you require support taking your medication? *

Yes
No

Do you use a Webster Pack? *

Yes
No

Any hospital admissions in the last 12 months? *

Yes
No

Provide full details of any admissions (including date and reason) *

History and Support

Do you have any past or current legal issues? *

Yes
No

If Yes, please provide details *

Are there any particular tasks you find challenging? *

Yes
No

If Yes, please provide details *

What support do you need? (Tick all that apply) *

Getting in/out of bed
Bathing
Dressing/undressing
With continence
Toileting
Washing
Cooking
Medication
Eating
Emotional support
Laundry
Shopping
Gardening
Cleaning
Keeping safe
Communicating
With documentation
Transport
Budgeting
Computer/IT skills
Social/family contact
Family relationships
Accessing medical/health appointments
Engaging with social groups
Advocacy (someone to talk on your behalf)
Information of services/support
Psycho-education (e.g. stress management)
Accessing counselling/talking to someone
Others

Please specify *

Additional comments

Consent

Terms and Conditions *

I acknowledge the information provided is true and correct. I agree that Abilities Housing Services may contact my health service providers to gather additional information to assist with my referral if needed. I consent to this referral being submitted for consideration of Abilities Housing Services.

Name *

Date *

If Guardian, provide a copy of your Guardian Order issued by the State Administrative Tribunal

Guardian Name

Date

Get In Touch

Head Office:
2/1 Commercial Avenue,
Dubbo, NSW 2830

Phone:
02 6882 7950

Email:
[email protected]

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