Application for Service Form


	Application for Service Date of Application: _________________________________________________ Surname: Ms/Mrs/Miss/Mr _________________________________________________________________ Given Names:______________________________________________________ Date of Birth: ____/____/_____ Address: _________________________________________________________________ _________________________________________________________________ Suburb: ____________________________________ Postcode: _____________ Telephone No: (Home) _______________________________________________ (Work) ______________________________ Preferred Language ____________________Interpreter Required? Yes / No What is your disability?
	[ ] cerebral palsy	[ ] polio
	[ ] spinal cord injury	[ ] spina bifida
	[ ] multiple sclerosis	[ ] other ____________________
	[ ] muscular dystrophy
	[ ] acquired brain injury

Please give a brief description of your disability

_________________________________________________________________

Communication requirements?

_________________________________________________________________

Secondary Disability / ties (if any)

_________________________________________________________________

What kind of housing are you looking for?

_________________________________________________________________

__________________________________________________

When?

_________________________________________________________________

In what area(s) do you plan to live?

_________________________________________________________________

__________________________________________________

Do you have your name on any of the following waiting lists?

	YES	NO	DATE LODGED
Office of Housing (Public Housing) If so, have you also lodged a Segmented waiting list application?	.	.	.
In Home Accommodation Support	.	.	.
Linkages	.	.	.
Service Needs Register - (Department of Human Services)	.	.	.
Support / Attendant Care - other agencies (please specify) ---------------------------------------------------------	.	.	.
Housing - other agencies (please specify) ---------------------------------------------------------	.	.	.
HACC Services	.	.	.

What, if any, other support is currently received?

_________________________________________________________________

Any other comments?

_________________________________________________________________

____________________________________________________

Signature: _________________________________Date: ___________________

A Housing Case Coordinator from the Housing Resource & Support Service will contact you as soon as possible.

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