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Private Rental Brokerage Program Referral
Private Rental Brokerage Program Referral
"
*
" indicates required fields
Referrer's Details
Name
*
Organisation
*
Role
*
Contact Number
*
Email Address
*
Date of Referral
*
MM slash DD slash YYYY
Young Person's Name
First Name
*
Last Name
*
Date of Birth
*
MM slash DD slash YYYY
Age
*
Gender
Male
Female
Other
Not Stated
Children
Contact Number
Email Address
Country of Birth
Aboriginal / Torres Strait Islander
Yes
No
Main Language Spoken
Cultural Identity
Emergency Contact
Name
Phone
Address
Relationship to Client
Eligibility for PRB
Untitled
Aged between 16-25 Years
Linked in with Key Support Worker with proven engagement
Receiving a stable income (including Centrelink)
Resides in or is moving to the Eastern Metropolitan Region
Is at the risk of experiencing homelessness or is homeless
Is identified as private rental ready or almost ready by key support worker
Want independent accommodation as a long term outcome
Has completed and attached a budget
Housing Situation
Current Address
Number
Street
Suburb
Postcode
Current Accommodation
Family
Friends
Other
Other Accomodation
Tenancy Issues
Rent Amount
Income
Type of Income
Wages
Job seeker payment
DSP
Parenting payment
Youth Allowance
Other
None
Income Other
Income Amount
Registered with Centrelink?
Yes
No
Centrelink Number (CRN)
Debts
Tenant Database Listing
Private Housing Debt
Public Housing Debt
Rent Arrears
Repayment Plans
Other Debts
Details if 'Yes' to any of the above
Education & Employment
Education
Enrolled In
School
Tafe
University
Course Name
Name of Institution
Expected Date of Completion
MM slash DD slash YYYY
Future Plans
Employment
Occupation
Name of Employer
Employment Conditions
Full Time
Part Time
Permanent
Casual
Housing Plan
Type of Dwelling
House
Unit / Apartment
Number of Rooms
Price Range
Type of Tenancy
Single Occupancy
Shared
Suburbs
Pets
How will the client look for rentals
Internet
Newspaper
Friends / Family
Real Estate Agents
All of the Above
How will the client pay for:
Bond
Rent In Advance
Essential Whitegoods
Other Linked Services
Comments
Needs Assessment
Legal
Drug and Alcohol
Mental Health
Disability
Health
Living Skills
Family Relationships
Gambling
Cultural
Support
Email
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