Adelaide Affordable Housing Application – Agency Referral

Below is the application form for Agency Referral to YWCA Australia’s Adelaide Affordable Housing property. For more information about the site, please visit the web page.

If you are an individual wanting to apply to this propety for yourself, please fill out this form instead.

Step 1 of 3

33%

Referral Agency

Referral Agency(Required)

Staff Member(Required)

First Last

Phone number(Required)

Email(Required)

Enter Email Confirm Email

Applicant Information

Applicant given name/s(Required)

Applicant surname(Required)

Has applicants name legally changed within the last 5 years?(Required)

Yes - we will request proof for the next stage

Applicant’s Preferred Name or Alias

First Last

Applicant Date of Birth(Required)

Please enter as dd/mm/yyyy

Applicant Gender(Required)

Female

Male

Transgender

Non-binary

Indeterminate

Applicant Mobile(Required)

Applicant Email Address(Required)

Enter Email Confirm Email

Applicant Alternative Contact Details

Applicant Country of Birth(Required)

Applicant Primary Language Spoken(Required)

Interpreter Required for Applicant?(Required)

Yes

Applicant Indigenous Status(Required)

Aboriginal

Torres Strait Islander

Both

Not applicable

Applicant Pets(Required)

Include number of pets, size and breed eg; 2 dogs, small, both chihuahuas

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

Yes

If yes, expected due date:(Required)

Please enter as dd/mm/yyyy

Is the applicant currently a car owner?(Required)

Yes

Additional Household Members

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

Yes

How many additional household members will there be?(Required)

Please note this refers to additional household members beyond the applicant themselves.

First additional household member

Name(Required)

First Last

Date of Birth(Required)

Please enter as dd/mm/yyyy

Relationship to Applicant(Required)

Gender(Required)

Female

Male

Transgender

Non-binary

Indeterminate

Type of Income(Required)

Gross Weekly Income(Required)

CRN(Required)

Second additional household member

Name(Required)

First Last

Date of Birth(Required)

Please enter as dd/mm/yyyy

Relationship to Applicant(Required)

Gender(Required)

Female

Male

Transgender

Non-binary

Indeterminate

Type of Income(Required)

Gross Weekly Income(Required)

CRN(Required)

Third additional household member

Name(Required)

First Last

Date of Birth(Required)

Please enter as dd/mm/yyyy

Relationship to Applicant(Required)

Gender(Required)

Female

Male

Transgender

Non-binary

Indeterminate

Type of Income(Required)

Gross Weekly Income(Required)

CRN(Required)

Fourth additional household member

Name(Required)

First Last

Date of Birth(Required)

Please enter as dd/mm/yyyy

Relationship to Applicant(Required)

Gender(Required)

Female

Male

Transgender

Non-binary

Indeterminate

Type of Income(Required)

Gross Weekly Income(Required)

CRN(Required)

Current Accommodation History

You only need to provide 2+ years of accommodation history. If the applicant has been at their current property for 2 years or more you do not need to supply a previous address.

Current Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is/was the applicant the:(Required)

Owner

Renter

How long at current address? (years, months)(Required)

Rental provider/Agent(Required)

Rental Provider/Agent Phone(Required)

Rental Provider/Agent Email(Required)

Rent paid(Required)

Per:(Required)

Week

Fortnight

Calendar Month

Current Employment

Current Occupation(Required)

Nature of employment(Required)

Full time

Part time

Casual

Self-employed

Other

If you answered other, please specify the nature of employment(Required)

Employer’s Trading Name(Required)

Employer Contact Name(Required)

Employer Contact Phone(Required)

Employer Contact Email(Required)

Employer Contact Address(Required)

Length of Employment (years, months)(Required)

Gross Income(Required)

This income is(Required)

per week

per month

If Self-Employed

Accountant's Name(Required)

Company Name(Required)

ABN(Required)

Phone

Email(Required)

If applicant receives a Centrelink payment

How many Centrelink payments does the applicant currently receive?(Required)

Centrelink Reference Number (CRN)(Required)

First payment: Type(Required)

Eg, Family Tax Benefit

First payment: Amount per fortnight(Required)

Second payment: Type(Required)

Eg, Family Tax Benefit

Second payment: Amount per fortnight(Required)

Third payment: Type(Required)

Eg, Family Tax Benefit

Third payment: Amount per fortnight(Required)

Fourth payment: Type(Required)

Eg, Family Tax Benefit

Fourth payment: Amount per fortnight(Required)

Needs and Risks

Applicant’s Housing Need:(Required)

Mental Health:(Required)

Please include current mental health supports

Disability and General Health:(Required)

Please include any support needs and details for service providers where appropriate.

Drug and Alcohol:(Required)

Is there a history of substance misuse? Please include any current or former supports.

Has the applicant or anyone in their household experienced domestic or family violence?(Required)

Yes

If yes, has an organisation supported them with (during or after) this experience?(Required)

Yes

Support Organisation Name(Required)

Was a Safety Plan completed?(Required)

Yes

Is there any ongoing risk to the applicant or any members of their family?(Required)

Yes

If yes, please specify(Required)

Formal supports - Support Agencies or Workers

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

Emergency Contacts and/or Next of Kin

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.

First Contact Person Name(Required)

First Last

Relationship to Applicant(Required)

Phone(Required)

Secondary Contact Person Name

First Last

Relationship to Applicant

Phone

Consent to Share Information

YWCA Australia (YWCA) will comply with relevant privacy legislation and standards for dealing with personal information as outlined in our Privacy Policy.

YWCA will work closely with other agencies to coordinate the best support for you. Your informed consent for the sharing of information will be sought and respected in all situations unless:

- we are obliged by law to disclose your information regardless of consent or otherwise,
- it is unsafe or impossible to gain consent or consent has been refused, or
- without information being shared, it is anticipated a child, young person or adult will be at risk of serious harm, abuse, or neglect, or pose a risk to their own or public health or safety.

Proposed use and disclosure of my personal information

The Applicants and each of them acknowledge and authorise the YWCA to make all necessary enquiries to verify the information provided herein, including information relating to employment, rental history and personal references under the provisions of the Privacy Act (SA) www.privacy.gov.au.

If you do not consent to the disclosure of your person information to those third parties we cannot process your application for a tenancy. We will collect and handle personal information about you in order to process your application for a tenancy. Primary Purpose Before a tenancy is accepted, we collect your information to assess the risk to our clients in providing you with the property you have requested to rent and, if considered acceptable, provide you with a tenancy for that property. In order to assess your application we disclose your personal information to:

- Referees to validate information supplied in your application
- Other Real Estate Agents to assess the risk to our clients

Secondary Purpose During and after the tenancy we may need to disclose your personal information to:

- Tradespeople to contact you for repairs and maintenance of the property
- Refer to Tribunals or Courts having jurisdiction seeking orders or remedies

Primary Purpose Consent(Required)

The primary purpose(s) of this service has been explained to the applicant and they have consented to the sharing of their personal information to assist in achieving the primary purpose(s).

Securing Private Information

YWCA Housing must comply with strict guidelines around who accesses the information and how the information is collected and stored. Applicant/Resident information is stored in accordance with The Privacy Act 1988 (Cth) and Privacy and Data Protection Act 2014 (Vic), all information will be stored securely to prevent loss or misuse.

Sharing to service providers(Required)

I, the service provider named above, have discussed with the applicant how and why certain information about them may need to be provided to other service providers.

They understand the recommendations and gave permission for the information to be shared as detailed above.

Acknowledgements and Declarations

Declaration(Required)

I, the referring agency worker named above, hereby confirm that the information provided above is true and correct as at the date of clicking 'submit application'

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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