Victorian housing intake form

Before you start this form, ensure you have a completed Consent to Share form to attach.

Download Consent to Share Form

Please select the type of referral(Required)

Myself

Someone else (agency referral)

About the service

Referring organisation

Referrer contact

First Last

Referrer email address

Referrer contact number

Referrer guarantees provision of Rent in Advance funding for applicant

Yes

No (Please note that the intake may not progress if not supplied)

About the person seeking support

Please note: YWCA will not accept applications from residents that have previously been evicted from a YWCA property or have outstanding arrears from a previous tenancy with us, until such time as an agreement is made to repay these funds.

Given name(Required)

Surname(Required)

Preferred name(Required)

Date of Birth(Required)

Gender(Required)

Assigned female/woman at birth

Transgender woman

Non-binary

Indeterminate

Please note: we are not currently accepting male applicants

Email address(Required)

Phone number(Required)

Current Address or Housing Situation(Required)

Country of Birth(Required)

Indigenous Status(Required)

Aboriginal

Torres Strait Islander

Both

None

Primary language spoken(Required)

Is an interpreter required?(Required)

Yes

Is the applicant or anyone in their household expecting a baby?(Required)

Yes

Does your client have any children in their care?(Required)

Yes

Source of income(Required)

Weekly Income Amount(Required)

Centrelink Reference Number (CRN)(Required)

Employment Status(Required)

Full-time

Part-time

Casual

None

Are there any pets?(Required)

Yes

Note: Rooming Houses are strictly No Pets

Include number of pets, size and breed

Is the applicant currently a car owner?(Required)

Yes

Registration/License Plate Number

Victorian Housing Register (VHR)

VHR Application Status (select all that apply)(Required)

Priority

Approved

Pending

Submitted

No Application

Was “Public and Community Housing” option selected when applying?

Yes

VHR Reference or Application Number (Required for all VHR Properties)

Priority Reason or Additional Information

Household Members

Is the applicant is the only person in their household?(Required)

Yes

Please share full name, date of birth, gender, relationship to applicant, type of income, gross weekly income and CRN for each household member.

Housing

If you don't have a response, please write N/A in the box.

Applicant’s Housing Need:(Required)

Applicant’s Housing History(Required)

Housing history including private rentals or rooming houses. Please include any previous public housing applications or tenancies.

Housing Area Preference(Required)

Please specify a YWCA vacancy if applicable, along with any other preferences the applicant has.

Unsafe Housing Areas(Required)

Needs and Risks

If you don't have a response, please write N/A in the box.

Mental Health(Required)

Please include current mental health supports

Disability and General Health:(Required)

Please include any support details

Drug and Alcohol:(Required)

Family and Domestic Violence:(Required)

History of Violence/Aggression:(Required)

Legal Issues:(Required)

Supports

If you don't have a response, please write N/A in the box.

Family and Relationships:(Required)

Formal Supports - Support Agencies or Workers:(Required)

Please include these agencies on the Consent to Share form, located at the end of this document.

Applicant’s Independent Living Skills:(Required)

Applicant’s Emergency Contact and/or Next of Kin(Required)

By providing this contact information, you provide consent for YWCA Housing to contact your nominated Emergency Contact and/or Next of Kin in emergency situations, or should you not be contactable to conduct welfare checks.

Consent to Share Signed?

Yes

Upload Signed Consent to Share here

Max. file size: 5 MB.

By ticking this box, you hereby confirm that the above provided information is true and correct as at the date of submission.(Required)

I do

YWCA Australia wishes to acknowledge the Traditional Owners of the lands on which we work, live and play and pay our respects to Elders past and present. We recognise First Nations people as the custodians of the lands, seas and skies, with more than 60,000 years of wisdom, connection and relationship in caring for Country.

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