The Trustees of the Society of St Vincent de Paul (NSW) ABN: 46 472 591 335
ABN 46 472 591 335 001
North Coast Settlement Service Auspiced by St Vincent de Paul Society NSW/ACT Funded by Department of Immigration and Citizenship (DIAC) Coffs Harbour Community Village 22 Earl Street Coffs Harbour NSW 2450 Ph: (02)6648 3670 Fax: (02)6650 0693 cheryl.nolan@vinnies.org.au
Ozanam Village 1 West Street Lewisham NSW 2049 PO Box 5 Petersham NSW 2049 Telephone: (02) 9560 8666 Facsimile: (02) 9550 9383 Email: vinnies@vinnies.org.au Website: www.vinnies.org.au Donation Hotline: 13 18 12
REFERRAL FORM Date of Referral: NB: Client must be aware of this referral. HISS Provider to include Exit Letter.
Referring Agency Details:
Client’s Details:
Agency:
Primary Client: Family Name:
Address:
Given Names: Date of Birth: Postcode: Relationship:
Contact: Name: Country of Birth: Telephone: Ethnicity: Mobile: Fax:
Client Two: Family Name:
Email: Still working with the client?
Given Names:
Client Contact Details:
Date of Birth:
Address:
Relationship: Postcode: Telephone:
Country of Birth: Ethnicity:
Mobile: Email: _______________________________________________________________________________________________________________ Every day in NSW the Society helps thousands of people through Home Visitation, Migrant and Refugee Assistance, Hospital Visitation, Prison Visitation, Aged Care Services, Vinnies Centres, Supported Employment Services for People with an Intellectual and other Disabilities, Hostels For Homeless Men, Women and Families, Overseas Relief, Disaster Recovery, Budget Counselling and Youth Programs.
Children: First Names
Surname
Date of Birth
Country of Birth
Ethnicity
Gender (M/F)
Relationship (see below)
Daughter – Son – Grandchild – Stepchild – Foster child – Adopted child – Friend – Other
Date of Arrival in Australia: Visa Type and/or Sub-Class ():
200 Other
Primary Language:
202
203
204
Specify: ................................................................................................................................... Other Language Spoken:
How well does the client speak English? () Is an Interpreter Required? ()
201
Very well
Well
Not well
Not at all
Yes Please explain why: ..................................................................................................................... No Please explain why not: ................................................................................................................
Employment: Qualifications Gained Overseas
Qualifications Gained in Australia
Work Experience Gained Overseas
Work Experience Gained in Australia
_______________________________________________________________________________________________________________
Main Source of Income:
Own Wages or Salary Another’s wages or Salary
Own Government Benefits Another’s Government Benefits
Is the client looking for work?
Yes No
If yes, Type of work
Is the client studying?
Yes No
If yes, what / where
Presenting Issues: ()
Health Household Management Tenancy Accommodation Child Care Migration Employment Transport
Education / Training Financial support Citizenship Income support Language Driving School / Homework Family / Relationships
Basic Transaction Skills Life Skills Rent Sport, Art and Craft Cultural Awareness Personal Relations Family Violence Practical Support
Child Protection No Extended Family Recently Relocated Social Participation Disability Legal Politics / Voting Community Development Advice
Additional Information:
Details of any other services the client is currently receiving (including sponsor and community groups, e.g. church):
_______________________________________________________________________________________________________________
Agency Use Only Date of first interview: Signed :_____________________________________________________________ Name: (Print )__________________________________________________ Position: ___________________________________________ Name of Volunteer assigned: ___________________________________________
_______________________________________________________________________________________________________________