Referral Form	ER 01

(Financial Crisis and Material Aid - Emergency Relief)

The Referral Form should be completed in consultation with the client(s) and the referring agency/referrer MUST obtain consent from the client(s) before referral. Service Types People in immediate financial crisis by providing financial or material aid Referrals Self-Reliance Support Eligibility Restricted to people unable to pay their bills or at the imminent risk of not being able to do so For residents in the following suburbs, the Emergency Relief support is Available in Auburn North, Auburn South, Auburn Central, Berala, Regents Park and Lidcombe. Limited, i.e. cannot guaranteed in Carlingford, Chester Hill - Sefton, Ermington - Rydalmere, Fairfield - East, Granville - Clyde, Greystanes - Pemulwuy, Guildford - South Granville, Guildford West - Merrylands West, Homebush Bay - Silverwater, Merrylands - Holroyd, North Parramatta, North Rocks, Northmead, Oatlands - Dundas Valley, Parramatta - Rosehill, Pendle Hill - Girraween, Rookwood Cemetery, Smithfield Industrial, Toongabbie - Constitution Hill, Wentworthville - Westmead, Winston Hills, Yennora Industrial Not available in other areas.

Referring Agency Details
Agency *:
Contact Person *:	Position:
Phone *:	Email *:

Client Details
Surname *:	Given Name *:
Gender *:	Female Male	Phone *:
Address *:
(Number and Street)
Suburb *:	Post Code *:
Language Spoken at Home (If NOT English) *:
Does the client require interpreter *:	Yes No

Family Details
Full Name	Relationship	DOB	Gender	Other Financial Information (Payslips, Centrelink Income Statement, etc.)
Reason for Referral (Please give as much information as possible)

Referrer’s Declaration
By signing this Referral Form, I have obtained consent, either in verbal or written format, from the client detailed above to release all information contained in this Referral Form to the Accessible Diversity Services Initiative Limited (ADSI).
I have attached a copy of my client’s Consent to be sent with this referral
Referrer Name *: (Please Print)	Referrer Signature *:
Date *:

Please send the completed form to ADSI via	Office Use Only
Email: er@adsi.org.au (Preferred), or Fax: 02 8737 5599	Date Received:
Date Assessed:
Assessment Outcome:	Eligible Not Eligible
Referral Allocated To: