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Referral
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Home / SHPP – At Risk Screening Tool

SHPP – At Risk Screening Tool

At Risk Screening Tool | Please use this form to complete a referral
Consent*
- Client consents to sharing of information between Access Health and Community, Uniting Harrison, SalvoCare Eastern and Launch Housing
Referrer Details
Your Name*
First Last
Organisation
Phone
Email*
Client Details
Client's Name*
First Last
Date of birth
Gender*
- Male
- Female
Email
Phone*
Address
Street Address Address Line 2
Municipality*
Clients can only be referred if they live in these municipalities. For all other referrals please call 1800 825 955
Interpreter Needed?*
- Yes
- No
Language
Relationship Status*
- Single
- Couple
- Sole Parent
- Family
- Unknown
Homelessness Risk Assessment
Does the client meet any of the following high risk referral criteria?
- Victim of domestic violence or home conflict
- 50% income spent on rent or mortgage
- Under 18 years of age and living away from home
- Rooming House resident
- Private rental on Centrelink payments
At risk of homelessness score
The client:
- is facing eviction or likely to abandon their home?
- has a history of previous institutionalisation?
- is undergoing family or relationship breakdown including domestic violence?
- does not have enough income to cover daily living costs
The client:
- has mental ill health issues
- has substance misuse issues
- displays anti-social behaviour
- displays lack of coping or practical skills
- has learning disabilities
- has a history of rough sleeping
- has a chronic medical condition
- is living in derelict Accommodation or evidence of hoarding
- is aged under 25
- is an indigenous Australian
- is single over 25 and living alone
- has caring responsibilities for children, or other dependants
Housing Situation and Property Information
What type of accommodation is the client living in?*
- Rooming house
- Community housing
- Sleeping rough
- Emergency accommodation
- Private rental
- Family
- Transitional housing
- Mortgage
- Public housing
- Couch surfing
- Student accommodation
- Supported Residential Service (SRS)
Tick all options that apply
- Is the client behind in rent or mortgage payments?
- Is the client struggling financially to pay rent?
- Has client received letters from landlord about tenancy?
- Is the client living in substandard or overcrowded housing?
Risk level and referral

Based on answers to these questions, this client is at risk and will be referred to .
Additional Notes
Other notes to accompany referral (attach a letter if required)
Attachments
A copy will be sent to the referrer email address.
Email
This field is for validation purposes and should be left unchanged.

Our current partners

Quick Links

Stable Housing Pilot Project
SHPP – Referral Flowchart
SHPP – At Risk Screening Tool (downloadable PDF)
SHPP – Frequently Asked Questions
SHPP – Launch Housing Referral Sheet
SHPP – SalvoCare Referral Sheet
SHPP – Uniting Harrison Referral Sheet
SHPP – High Risk Referral Sheet
Protecting your Privacy

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Last Name

Email

Phone

Subject

Message

I have read and understood the AccessHC privacy policy

After-hours contacts

For after-hours assistance regarding AccessHC property and security call 0466 501 902 .

For after-hours medical care call 132660 .

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Access Health and Community acknowledges the Wurundjeri Woi-wurrung people, who are the Traditional Owners of the land on which we work. We pay our respects to Wurundjeri Elders past and present and future, and extend that respect to other Aboriginal and Torres Strait Islander people. We acknowledge that sovereignty was never ceded.

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Client Details
Name*
First Last
DOB*
Date Format: DD slash MM slash YYYY
Address Line 1
Address Line 2
Phone number*
Does the client have a carer or alternate contact person?
Name
Phone Number
Referrers Details
Name*
First Last
Company
Role
Phone*
Email*
Why are you referring the client?*
What service(s) are you referring them to*
Attach the referral below

Carer or contact person
Name*
First Last
Email*
Phone*
Need an interpreter?*
- Yes
- No
Choose Language

Referrer
Name*
First Last
Company
Role
Phone number*
Email*
Why are you referring the client?*
What service(s) are you referring them to*
Attach the referral below

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