Get help for my client

Step 1 of 9 - Initial Statement

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Please fill out this referral form to request help for your client from SASSI.

SASSI is a homelessness service working with women who need support to address housing issues. Is your client currently homeless or at risk of homelessness?*

This might include: They have been asked to leave your home because their tenancy is ending or they have been evicted; They are staying in insecure, unstable or short-term accommodation (e.g. couch surfing, refuge, Temporary Accommodation or staying with friends); They are staying somewhere unsafe (e.g. with a violent partner or family member); Their accommodation is no longer suitable (e.g. it is not suited to their mobility or medical needs or is overcrowded)

Yes

Is your client a woman (or do they identify as female or non-binary)?*

Yes

Is your client aged 16 or over?*

Yes

Is your client living in the Illawarra or the Shoalhaven (or, if not, are they looking for crisis accommodation in this region)?*

Yes

SASSI cannot provide housing or support to adult males. Can you confirm that the client is seeking support for herself and any children only?*

This can include dependent male children of any age

Yes

Based on your answers, your client may not be eligible for our services. Please call our office to discuss their eligibility and how SASSI may be able to assist.

Referring agency*

Referrer's name*

Referrer's email*

Referrer's phone number*

What kind of support are you providing to this client?*

Advocacy

Referrals

Case management/case coordination

Health care (e.g. mental health, medical care, aged care)

Other

Please explain other types of support you're providing this client:*

How long has your agency been supporting this client?*

Less than one month

1 month

1-6 months

6-12 months

More than 12 months

Will your agency continue to support this client?*

Yes, however client requires additional specialist homelessness support from SASSI

No, our service cannot provide support to this client

We will provide support until the client is allocated a SASSI caseworker

What outcome are you hoping to achieve from this referral?*

Crisis accommodation

Transitional housing

Outreach case management

Other

What region is your client in?*

Illawarra (from Helensburgh to Gerroa)

Shoalhaven (from Berry to Durras)

Neither, but they would like to be considered for crisis accommodation in Shoalhaven

Neither, but they would like to be considered for crisis accommodation in Illawarra

What suburb is your client currently staying in?*

What other location or suburb is your client staying in?

Your client's name (First)*

Your client's name (Surname)*

Client's date of birth*

Day

Month

Year

Does your client identify as:*

Aboriginal

Torres Strait Islander

From a migrant or refugee background

Living with a disability

LGBTQIA+

None of the above apply

Does your client have any accessibility needs that it would be useful for SASSI to know about prior to assessment (for example, hearing impairment)*

Yes

Please tell us more about their accessibility needs so we can do our best to meet them:*

Would your client find it useful to have an interpreter for their first phone call with SASSI?*

Yes

What language do they require interpretation for?*

Who is seeking support? (please do not include children not currently in the client's care)*

Client only

Client and child/children

About your client's children*

Please type in your answers below each question. If your client has more than 1 child, click the plus icon on the right to add their details.

Child's first name

Child's surname

Child's DOB (DD/MM/YYYY)

Child's sex (Female, Male, Non-binary)

Is there anything important you'd like to tell us about this child (e.g. support needs, child protection or custody arrangements)? If none, please write N/A.

SASSI will need to speak to your client on the phone to conduct our initial assessment. Please provide information so we can contact them safely.

Client's phone number*

Client's email (optional)

Is it safe for SASSI to call your client on the phone number provided?'*

Yes, it safe to call the client

Yes, it is safe to call the client but please do not SMS or leave a voicemail message

No, it is not safe to call the client

SASSI wants to make sure that contacting clients does not place them in any danger.

Please let us know how we can contact them safely (e.g. if there is a safe time to call or another way to contact them safely, for example, texting to set up a time to call).

Please let us know if there is any more information that will help us contact the client safely (for example, if there is a safe time to call, or a time to avoiding calling them)

Tell us about your client's housing circumstances. Are they:*

Currently homeless (e.g. in Temporary Accommodation, rough sleeping, sleeping in their car)

At risk of homelessness (e.g. issued an eviction notice, unable to stay where they are)

Unsafe in their current housing (abuse/violence, family violence, domestic violence, or poor property condition)

Finding their housing unsuitable for their needs (mobility restrictions, overcrowding, location)

In unaffordable accommodation

Has domestic or family violence impacted your client's current situation, as far as you are aware?*

Yes

Please provide as much relevant information as you can about the client and their situation, to help inform our initial assessment. In particular, please make us aware of any risk factors which might affect the client or SASSI staff.

Thank you for filling out this form. Click the submit button below to submit your answers.

Self Referral

Agency Referral

Counselling Referral

Agency referral form

Referral Form (Agency)