FIRST NAME*
FAMILY NAME*
DATE OF REQUEST*
EMAIL*
ORGANISATION REQUESTING ASSISTANCE
DATE OF BIRTH
SUBURB*
GENDER --NONE-- MALE FEMALE OTHER
CLIENT CONTACT NUMBER*
ENGLISH PROFICIENCY --None-- Low Limited Adequate Fluent
DATE CLIENT MOVED INTO PROPERTY
PREFERRED LANGUAGE*
HOW MANY OTHER RESIDENTS?*
HOW MANY ADULTS NEED ASSISTANCE?
EMERGENCY ASSISTANCE REQUIRED --None-- Bed base (single) Bed base (king single) Bed base (double) Bed base (queen) Bed base (king) Mattress (single) Mattress (king single) Mattress (double) Mattress (queen) Mattress (king) Bed head (single) Bed head (double) Bedside Tables Wardrobes Chest of Drawers Dining Table and Chairs (as a set) Dining Table Dining Table Chairs Coffee tables Study desks Sofa (2 seater) Sofa (3 seater) Sofa (4 seater +) Arm Chair TV Table Entertainment Units Kitchen packs Food Linen Fridge Washing Machine Clothes Dryer TV Set Top Box Fan Heater Vacuum Cleaner Microwave PC Laptops Prams Stroller Cot Bassinet Baby car seat Nappies Toys
HOW MANY CHILDREN?
COMMUNITY PROGRAMS
EMPLOYMENT & TRAINING PROGRAMS --None-- Pre-Employment Training & Support Practical Work English Practical Training
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* --None-- Cash Credit Card Direct Deposit
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
