Referral	Form	FORM 01

(Settlement Services)

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 Casework, Community Development, Youth Settlement, Support for Ethno-specific Communities Eligibility Permanent residents who have arrived in Australia in the last five years as: Humanitarian entrants, and Family stream migrants with low English proficiency, and Dependants of skilled migrants in rural and regional areas with low English proficiency. Selected temporary residents (Prospective Marriage and Provisional Partner visa holders and their dependants)

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

Client Details
Surname *:	Given Name *:
Gender *:	Female Male	Phone *:
Address *:
(Number and Street)
Suburb *:	Post Code *:
Country of Birth *:	Ancestry *:
Nationality *:	Date Arrived in Australia *:
Language Spoken at Home (If NOT English) *:
Visa Holder *: (Is the person the principal or dependant?)	Yes No
Does the client require interpreter *:	Yes No

Family Details
Full Name	Relationship	DOB	Gender	Other Information (School/Allergy/Disabilities)

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 Visa 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: info@adsi.org.au (Preferred), or Fax: 02 8737 5599	Date Received:
Date Assessed:
Assessment Outcome:	Eligible Not Eligible
Referral Allocated To: