New Client Expression of Interest Form
Complete and submit your details below, using the online expression of interest form in order to receive disability support services from The Housing Connection.

Otherwise, you can click here to download and print this form, and then send it by mail or in person to The Housing Connection. Go to the contact page for more details.

All information collected by The Housing Connection will remain confidential in accordance with the Federal Privacy act 1988.

Date of Application:

Who is making this referral?:

Name of person being referred:

Address:

Telephone:

Email:

Date of Birth:

Type of Disability:

ADHC Caseworker Involved?:  Yes No

Advocate:  Yes No

Name of Advocate?:

Do you have ADHC, HACC, or other funding?:

Are you applying as a fee for service client:  Yes No

Where are you currently living?:  With Parents Aged Parents Other family member

Do you want to move?:  Yes No

Where would you like to live?:

Who would you like to live with?:

Are you on the Department of Housing List?:  Yes No

Are you on the Community Housing List?:  Yes No

What type of support will you need?:

 Support to live in my own home (drop in support)

 24 hour support

 Support to participate fully in community living

 Workskills and pre-employment training

 Other (individualised and self managed funding will enable you to use available resources in flexible ways that meet your personal needs)

What do you do during the day?:  Open employment Adult day placement Workshop Other Volunteer

What are your interests?:

Other relevant information (e.g. any complex or challenging behaviour):

Do you give permission for further information to be sought in the process of completing this application?:
 Yes No

Signature:

Please note the placement of all eligible clients into accommodation vacancies in the Metro North Region is now managed through the Ageing, Disability & Home Care’s Vacancy Management System. People with a disability who wish to access a service such as The Housing Connection (funded by ADHC) must be assessed for eligibility and priority by the Community Access Information, Intake and Referral Team contactable on Ph: 9895-8659 and endorsed by the Regional Manager, Community Access. However, you will be able to list The Housing Connection as a preferred service provider.

Signed:

Date: