Service Linkage Referral Form

Introduction

IRT Foundation’s Service Linkage program is helps prevent homelessness of older people in the Illawarra through early intervention and ongoing support. Goals-based service mapping links vulnerable older Australians who have been homeless or who are at risk of homelessness to the services they need to age well.

The aim of this program is to minimise barriers for clients to access existing community services and support people to link into those services.

Referral criteria

Must be over 55 years of age, or Aboriginal and/or Torres Strait Islander over 50 years of age and residing in the Illawarra region.

Referral process

Agencies and organisations can make referrals to IRT Foundation’s service Linkage program by completing the below referral form. Our Service Linkage worker will complete a holistic assessment considering the client’s level of need, opportunity for re-ablement, level of support required (e.g. disability, care, drug and alcohol, mental health), compatibility with current and potential housing options and personal preferences to facilitate choice and control. Entry into the program is dependent on case load, urgency or level of need, and the discretion of IRT Foundation. The program is not designed to replicate other existing targeted services, so clients may be referred to more appropriate services.

We help our clients establish and achieve goals that are meaningful to them. Each client’s unique needs are discussed and client activities are mapped across personal outcomes areas such as:

- Safety and health- Social networks- Empowerment- Resilience

- Employment participation- Better mental health- Life satisfaction- Social inclusion

Clients can continue receiving support until choosing to exit the program and may re-enter at any stage. The program is completely funded by IRT Foundation with the majority of referrals coming through our Assistance with Care and Housing program.

If you would like further information, please contact us:

134 478 irtfoundation@irt.org.au

IRT Foundation Referral Form Service Linkage

All information in this document is treated in the strictest confidence.

Title: Mr Mrs Ms Miss

Date of birth:

Interpreter required? Yes No

Aboriginal or Torres Strait Islander?

Yes No Both

Yes No

Name:

Address:

Phone:

Place of birth:

Nationality:

Language:

Pension type:

Mailing address

Any known substance abuse?

Is there a diagnosed mental health illness?

If yes, is there a caseworker involved?

Current housing situation:

Do you own a pet?

Section 1 - Personal details

Client 1

Title: Mr Mrs Ms Miss

Name:

Date of birth:

Email:

Mobile No.:

Place of birth:

Nationality: Years in Australia:

Language: Religion:

Client 2

Savings?

Empowering older Australians

Section 3 - Details of the person making the referral

Name:

Agency they work for:

Reason for referral:

Is the client aware of the referral? Yes No

Can the person/service accompany you to the assessment?

Yes No

Date of referral:

Section 4 - Care

Section 2 - Current care supports

Formal support arrangements:Informal support arrangements:

Interpreter required? Yes No

Language:Aboriginal or Torres Strait Islander?

Yes No Both

Pension type:

Any known substance abuse?

Any known mental health problems?

Is there a diagnosed mental health illness? Yes No

If yes, is there a caseworker involved?

Current housing situation:

Aged care assessment attached: Yes No

Nominated contact 1:

Address:

Phone:

Power of attorney: Yes No Guardian: Yes No

Guardian: Yes No

N/A

Nominated contact 2:

Power of attorney: Yes No

Address:

Phone:

All information in this document is treated in the strictest confidence.

Savings?

Phone:

Attn: Gail Puckeridge Assistance with Care and Housing Coordinator Attn: Brooke Costanza Service Linkage CoordinatorT 134 478 E irtfoundation@irt.org.au

ID[ ] ACH [ ] Service Linkage

Please complete this simple survey to help us measure our service.

Your responses will not affect the level of service you receive as this information will be completely separated from your client record and held in confidence with our privacy policies.

Date of Birth ___/___/______ DEM1DOB

Gender Male Female OtherDEM2GEN

Which option best describes your current marital status?

Married (in a registered marriage) Separated, but not divorced DivorcedWidowed Never married, but living with someone in a relationship Never married, and not living with someone in a relationship Don’t know

DEM3MARITAL

Do you (or any other members of this household) own your home, rent it, or do you live rent free?

Own / currently paying off mortgage Rent (or pay board) Involved in a rent-buy scheme Live rent free / Life Tenure Prefer not to answer Don't know

DEM4HOMEOWN

How much do you spend per week on rent or mortgage payments where you are currently living?

$__________ per week

DEM5RENT

Which statement best describes your current level of savings (including cash, bank deposits and other savings like bonds and term deposits)? (select one only)

If you have savings, approximately what is the total balance?

I have no savings I have very little savings (equal to less than 1 month’s income) I have limited savings (equal to 1-2 months’ income) I have moderate savings (more than 3 months income) I have significant savings and investments Don’t know

Less than $500 $5000 to $10,000 $500 to $2999 $10,000 or more $3000 to $4999 Don’t know

DEM6SAV

IRT Foundation client survey

ID:

Which of the following statements best describes your current level of debt?

Excluding your mortgage, approximately what is your combined outstanding debt?

(select one only) I am over-indebted (my debts are larger than my ability to repay them) I have debts that I am just managing to repay I have debts that I am managing to repay comfortably I have debts and I am managing to repay these very comfortably I have no debts Don’t know

Less than $3000 $3000 to $4999 $5000 to $10,000 $10,000 or more Don’t know

DEM7DEBT

How many people, including yourself, live in your household?

Number of people in household ___ Don't know Prefer not to say

DEM8HOUS

Do you have any financial dependants?

A financial dependant is a child under the age of 15, or children 15-24 years who live with you more than half of the time and for whom you provide financially, or other persons for whom you provide financially.

Yes No

IF YES, 1. How many under 15 ____2. How many 15-24 years ____3. How many 25 years + ____

DEM9DEP

What was the highest year of school you completed?

Year 12 or equivalent / Senior Secondary Year 11 or equivalent Year 10 or equivalent / Junior Secondary Year 9 or equivalent Year 8 or equivalent Year 7 or equivalent Did not attend secondary school but finished primary school Attended primary school but did not finish Prefer not to say Don’t know

DEM10EDU

ID:

What qualifications have you completed? Select each type of qualification completed. Do not include hobby or recreation courses.

Secondary school qual. - lower level Secondary school qual. - highest level Nursing qualification Teaching qualification Trade certificate or apprenticeship Technicians cert. / Advanced certificate Other certificate - level I Other certificate - level II Other certificate - level III Other certificate - level IV Other certificate - Don’t know level Associate diploma/Diploma (2 yrs full-time or equivalent) Associate Degree Undergraduate diploma / Advanced diploma (3 yrs full-timeor equivalent) Bachelor Degree but not Honours Honours Bachelor Degree Graduate Certificate Post-graduate Diploma/Graduate Diploma Masters Degree Doctorate Other (specify ) Did not complete qualification Still studyingPrefer not to say Don’t know

DEM11QUAL

ID:

(please tick)

…your life as a whole?

IND74LIFESAT1

…your standard of living?

IND74LIFESAT2

…your health?

IND74LIFESAT3

…what you are achieving in life?

IND74LIFESAT4

…your personal relationships?

IND74LIFESAT5

…how safe you feel?

IND74LIFESAT6

…feeling part of your community?

IND74LIFESAT7

…your future security?

IND74LIFESAT8

Notes ________________________________________________ Date completed ________

0 1 2 3 4 5 6 7 8 9 10

Not at all satisfied Completely satisfied

0 1 2 3 4 5 6 7 8 9 10

Not at all satisfied Completely satisfied

0 1 2 3 4 5 6 7 8 9 10

Not at all satisfied Completely satisfied

0 1 2 3 4 5 6 7 8 9 10

Not at all satisfied Completely satisfied

0 1 2 3 4 5 6 7 8 9 10

Not at all satisfied Completely satisfied

0 1 2 3 4 5 6 7 8 9 10

Not at all satisfied Completely satisfied

0 1 2 3 4 5 6 7 8 9 10

Not at all satisfied Completely satisfied

0 1 2 3 4 5 6 7 8 9 10

Not at all satisfied Completely satisfied

Thinking about your own life and personal circumstances, how satisfied are you with…

…the home in which you live? 10

IND74LIFESAT9

0 1 2 3 4 5 6 7 8 9

Not at all satisfied Completely sati sfied

10