Private Rental Brokerage Program Referral

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Referrer's Details

Name*

Organisation*

Role*

Contact Number*

Email Address*

Date of Referral*

Young Person's Details

First Name*

Last Name*

Date of Birth*

Age*

Gender
MaleFemaleOtherNot Stated

Children

Contact Number

Email Address

Country of Birth

Aboriginal / Torres Strait Islander
YesNo

Main Language Spoken

Cultural Identity

Emergency Contact

Name

Phone

Address

Relationship to Client

Eligibility for PRB

Aged between 16-25 YearsLinked in with Key Support Worker with proven engagementReceiving a stable income (including Centrelink)Resides in or is moving to the Eastern Metropolitan RegionIs at the risk of experiencing homelessness or is homelessIs identified as private rental ready or almost ready by key support workerWant independent accommodation as a long term outcomeHas completed and attached a budget

Housing Situation

Current Address

Number

Street

Suburb

Postcode

Current Accommodation

FamilyFriendsOther

Tenancy Issues

Rent Amount

Income

Education & Employment

Education

Enrolled in
SchoolTafeUniversity

Course Name

Name of Institution

Expected Date of Completion

Future Plans

Employment

Occupation

Name of Employer

Employment Conditions
Full TimePart TimePermanentCasual

Housing Plan

Type of Dwelling
HouseUnit / Apartment

Number of Rooms

Price Range

Type of Tenancy
Single OccupancyShared

Suburbs

Pets

How will the client pay for:

Bond

Rent In Advance

Essential Whitegoods

Needs Assessment

Legal

Drug and Alcohol

Mental Health

Disability

Health

Living Skills

Family Relationships

Gambling

Cultural

Support

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