Referral Form

FRIENDS OF REFUGEES REFERRAL FORM

Please fill out as much details as possible to help us assist your clients who are in need of our assistance through our various programs. We are a unfunded volunteer based organisation, so processing times depends on volunteers availability. If the assistance required is of urgent nature, we encourage you to fill out the form below and send the client with a referral letter to our drop in centre.

FIRST NAME*

FAMILY NAME*

DATE OF REQUEST*

EMAIL*

ORGANISATION REQUESTING ASSISTANCE

DATE OF BIRTH

SUBURB*

GENDER

CLIENT CONTACT NUMBER*

ENGLISH PROFICIENCY

DATE CLIENT MOVED INTO PROPERTY

PREFERRED LANGUAGE*

HOW MANY OTHER RESIDENTS?*

HOW MANY ADULTS NEED ASSISTANCE?

EMERGENCY ASSISTANCE REQUIRED

HOW MANY CHILDREN?

COMMUNITY PROGRAMS

EMPLOYMENT & TRAINING PROGRAMS

CASE MANAGER NAME

AVAILABILITY

CASE MANAGER PHONE NUMBER

CASE MANAGER SITE LOCATION

EMPLOYMENT STATUS*

VISA STATUS*

DOES CLIENT RECEIVE CENTRELINK SUPPORT?*

ADDRESS*

COMMENTS

PHYSICAL HEALTH

AGE

MENTAL HEALTH

ESTABLISHED HOUSEHOLD?

ANY DETAILS TO HELP US ADVOCATE?

SCHEDULE OF FEES AND CHARGES (Please note: The charges are for delivery fees, household items are FREE of cost and minimal costs to test and tag white goods which is mandatory)

MEANS TESTED AT FOR(special needs clients, newly arrived, long term unemployed-need documentation)[0$]
YES

DELIVERY TO OTHER SOUTHEASTERN SUBURBS [50$]
YES

DELIVERY TO DANDENONG, NOBLE PARK, SPRINGVALE, DOVETON, KEYSBOROUGH [40$]
YES

LARGE WHITEGOODS [20$] (e.g. fridges, washing machines, dryers)
YES

MEDIUM WHITEGOODS [10$] (e.g. microwave, heater, cooler)
YES

SMALL WHITEGOOD [5$] (e.g. kettle, toaster, rice cooker, blender)
YES

ACCEPTED PAYMENT METHODS*

I have informed the client about the fees and charges and that the payment has to be completed before FOR processes the request*
YES

Our agency will bear the cost*
YES

*Required Fields

FRIENDS OF REFUGEES REFERRAL FORM

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