Friendship House – Home For Good. Referral Form1
Friendship House & Home for Good Project - Post Release Support
Referral Form & Cover Sheet
Attention: Friendship House/Home For Good Fax: (02) 4922 1560Dept. of Corrective Services Facility/Other Services: …………………………….……
Client Name: ……….……………………………………………………………………….
MIN: ……………………………………………..……………………………………………
Planned Release Date: …………………………………………………….………………
Referred by: …………………………………………………………………...……………
Position/Agency: ……………………………………………………………………….…..
Contact Details Ph.………………………………Mob…………………………….….….
Email: ………………………………………………………….…………..….
The Samaritans will treat all personal and health information provided as private and confidential. The health information in this referral form is to be collected with the applicant’s consent. The information will be used to determine the applicant’s suitability for the Friendship House or Home For Good Project. The information will be held within the team of the Friendship House/Home For Good Advisory Committee, consisting of staff and volunteers.The application to Friendship House/Home For Good might be declined should the applicant decide not to provide their information.
Please fax or email this form to Samaritans - Friendship House/Home For Good Committee – email:Fax (02) 4922 1560 Phone (02) 4922 1500- 32 Brunker Road, Broadmeadow, NSW 2292
Please include Criminal History for Friendship House application
Friendship House/Home For Good,Use Only
Received Date: …………………… ………………….. Telephone Interview Date: ………………………......
FH/HFG Committee Decision Date: ………………………… Accept: …………………… Reject: ………………
Rejection Reason: ………………………………………………………………………………………………………
Program Start Date: ………………… …………..………Program Finish Date: …………………………………..
Comments: ………………………………………………………………………………………………………….….
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Friendship House – Home For Good. Referral Form1
As this is a combined form for Friendship House and Home For Good
Friendship House – Home For Good. Referral Form1
not all questions will be applicable for each application.
Personal Details/Cultural Identity:
Surname ……………………………Given Names ………………………………….………..
DOB ……………………….Age …………… Country of Birth: ………………….…………..
Married □Partner □ Divorced/Separated □ Single □
Aboriginal/Torres Strait □Anglo/Australian□ Other: ………………………………
Preferred Language(If other than English): ………………………………………………………….
Is interpreter required? Yes□ No □
Address if not in Prison(If homeless state homeless)
(Number and Street) ………………………………………………
Suburb: ………………………………………………………. Postcode: ………………………
Phone: ………………………………….. Mob: …………………………………………………..
Centrelink and Income Source before entering prison or current:
NEWSTART □ DSP □ PENSION □ WAGES□ OTHER: …………………………….
Centrelink number ………………………………
Guardianship: Yes □No □
Have you accessed Centrelink? (In prison or/since leaving prison)Yes □No □
Does the applicant have a Centrelink debt?, Yes□No□;
if Yes, has the applicant resolved debt payments with CentrelinkYes□No□
Documentation/Bank Account
Does the applicanthave a birth Certificate?: Yes □ No □
Does the applicant have an active Bank Account?: Yes □No □
If the applicant does not have a bank account does the applicant have documentation to reach 100 points? Yes □ No □
State Debt
Does the applicant have a State Debt? Yes □ No □,
If yes, has the applicant organised a repayment plan with State Debt?: Yes □ No □
Accommodation:
What type of accommodation does the applicant livein now/or lived in prior to prison(e.g. Housing NSW, Private Rental, Friends, Homeless, Boarding House, Own House, Couch Surfing)
………………………………………………………………………………………………………..
Does the applicant have a T Number?, If Yes, what is the number: ………………………….
Has the applicant lodged an application form with Housing NSW?, Yes □ No □
or Compass Housing?Yes □ No □
Does the applicant have a Housing NSW debt?, If yes, has the applicant worked out a debt repayment plan with Housing NSW?. Yes □ No □
Offence Details:
Date of Entry to prison ……………………….Earliest Release Date…………………………………
Offence……………………………………………………………………………………………………..
Any Parole/How Long? ……………………………………………………………………………………
Is this the first sentence served by the applicant? Yes □ No □
What other sentence/s has the applicant served, (if any):
When / Offence / Sentence?Do you have any current AVO’s?: Yes □ No□
If Yes what are they? ………………………………………………………………………………
Are there any special conditions/requirements in place upon release or currently.
………………………………………………………………………………………………………….
Drug Use History (Please circle)
Which of the following drugs has the applicant used on a regular basis?
Alcohol Amphetamines Anti-depressants Barbiturates Cannabis Ecstasy
Hallucinogens Heroin Nicotine Tranquilisers Other Prescription Drugs
Which of the following has the applicant had a problem managing in the past?
Alcohol Amphetamines Anti-depressants Barbiturates Cannabis Ecstasy
Hallucinogens Heroin Nicotine Tranquilisers Other Prescription Drugs
What drug use (if any) does the applicant currently feel they are trying to manage/eliminate/reduce?
Alcohol Amphetamines Anti-depressants Barbiturates Cannabis Ecstasy
Hallucinogens Heroin Nicotine Tranquilisers Other Prescription Drugs
Please describe Applicant’s current status re drugs as accurately as possible:
…………………………………………………………………………………………………………
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What rehab or other treatment programs have been undertaken?
Rehab/Program / When & Duration / Outcome Completed?/Usefulness?Medical and Addictions;
Is the applicant currently on any medication/s? Yes □ No □
For what? ………………………………………………………………………………………..….
Treatment Plan ……………………………………………………………………..……………...
Has the applicant had any formal psychiatric diagnosis? (Please describe) Yes □ No □
For what? ………………………………………………………………………….
Treatment plan ……………………………………………………………………
Has the applicant ever had a gambling problem?Yes □ No □
Amount/Duration …………………………………………………………………
Treatment Plan ……………………………………………………………………
Does the client have any other medical issues/allergies? Yes □ No □
What?......
Treatment plan ……………………………………………………………………
Family and Support;
Brief Summary of immediate family, Mother/Father/brothers/sisters/significant others.
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Who does theapplicant expects to have contact with - friends / family / community connections? …………………………………………………………………………………………
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Any other supports? ……………………………………………………………………………….
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Name and Age of Children(any constraints on seeing your children?) …………………………
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Does Applicant have any Legal/Parole/Community Service Order Issues?
Yes □ No □
Issues………………………………………………………………………………………………
Do you need legal representation?:(describe)…………………………………………………......
Employment History:
Currently or before entry to prison: ……………………………………………………………….
……………………………………………………………………………………………………….
What is the applicantswork history in prison?: …………………………………………………..
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What training/qualifications/skills has the applicant achieved?e.g. Green Card:…………...
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Does the applicanthave any training requirements? ……….…………………………………
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Other Services:
What other non government services has the applicant accessed?:…………………….…
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Personal Attitudes/Interests:
What changes has the applicant made or wants to make in their life that will help prevent
Reoffending?:……………………………………………………………………………………....
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How can Friendship House/Home For Good help with this change in your life?:………….
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What personal issues/goals are the applicant working on, both long and short term?
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What areas of interest/recreation does the applicant have? …………………………………
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Any other relevant information that would assistthe applicant’s referral approval?:
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Please attach relevant copies of certificates etc. to enable liaison and planning prior to release.
FOR FRIENDSHIP HOUSE APPLICANT’S ONLY
Applicant’s Declaration:
I agree to the release by the referrer of a list of my previous offences/convictions for the purpose of applying for the Friendship House Program.
Applicant’s Name: ………………………………………………………….
Applicant’s Signature: ……………………………..…………………………..
Date:………………………………………………………….
NB Have you included a copy of the Applicants Criminal History?
FRIENDSHIP HOUSE AGREEMENT POLICY FOR RESIDENTS
The Terms of Occupancy are designed for the benefit of clients and volunteers to maximize the use of Friendship House in the local community. Therefore there is an expectation that residents will participate in all aspects of the Friendship House Program. As a shared facility under the control of a management committee this agreement is outside the ‘Residential Tenancies Act 1987’. Clients occupy the Friendship House premises as boarders not tenants
1)The standard length of occupation is 4 weeks
2)Advance payment of $220.00 is required before the client takes up occupancy. This amount comprises of 4 weeks rent @$45 per week plus a returnable (house to be left in clean and tidy condition) key deposit of $40.00.
3)Friendship house accommodates 2 men, one in each of two bedrooms.
4)If a client is evicted or chooses to leave the house Pro-Rata rent will not be refunded.
Signature of Resident………………………………………………….
5)Residents are required to participate in a support program with the Friendship House volunteer committee towards individual goals and securing long term accommodation
6)Residents are required to meet with the volunteers a minimum of 3 times per week.
7)Volunteers are in their position to assist residents to the full extent of their ability and as such shall be treated in a respectful manner.
8)Residents are required to create a case plan with the Coordinator within the first 3 days of their stay.
9)Residents are required to meet with the coordinator weekly to review their case plan.
10)A weekly evaluation of the resident’s case plan will be conducted with the resident and an assessment of their goals will be discussed to determine their continuing suitability for Friendship House.
11)If a resident is going to be absent from the House they need to inform a member of the Management Committee. This relates to a general concern for the residents welfare, and the importance of keeping lines of communication open.
Signature of Resident………………………………
12)Illegal activities of any nature are not to take place at the House.
13)Illegal drugs and alcohol are not to be bought into or consumed at Friendship House
14) Issuing threats or acting in a threatening manner to other clients in Friendship House or neighbours will lead to removal from the Friendship House program.
15) Clients are required not to approach the general public to solicit money or other goods. This includes the surrounding residences.
16)No visitor overnight stays are permissible. No visitor is to adversely affect the other resident.
17)Residents are responsible for any damage to the property other than general wear and tear
18)Residents are asked to contribute to a positive relationship within the immediate local community. This relates to such issues as noise, general behaviour and demeanour.
19)Signed agreement to abide by this Policy is necessary to take up residence.
20)If a resident breaks any agreement of the policy the Management Committee will discuss the matter with the resident and the resident will generally be given 24 hours notice. This notice may be reduced if the infringement is deemed serious enough.
Signature of Resident………………………………………………….
RESIDENTS RIGHTS
21)Residents will receive a receipt for all payments
22)Personal Information disclosed to the Friendship house Management Volunteer Committee will be treated with the strictest confidence
23)All residents are encouraged to raise any concerns with members of the volunteer committee or directly with the Samaritans staff member co-coordinating the project.
24)Any changes to Friendship house terms of occupancy will be discussed with the residents for their input.
25)Residents will be provided with an evaluation/feedback form as an opportunity to give formal feedback to the Samaritans Foundation about all aspects of their stay at Friendship House.
I agree to comply with the responsibilities set out in this Occupancy Agreement
Name of resident…………………………… Signature of resident………………………………
Name of witness………………….………… Signature of witness…………………………..…..
Date………………………..