Public Tenancy Support Service (PTSS)

Please email to your local PTSS service provider

REFERRAL DETAILS:
Date of referral: / Tenant Account number:
HSO:
Team Leader: / Ph: Email
Ph: Email
TENANTS DETAILS: Indicate if this tenancy is subject to ‘TWO OFFICERS TO ATTEND’

Name 1:

Name 2:
Address:
Phone: / Date of Birth 1: / Date of Birth 2:
Aboriginal / Yes / No
Torres Strait Islander / Yes / No
Aboriginal and Torres Strait Islander / Yes / No
Other, please specify
Language preference:
Employment/School & Grade:
Gender
OTHER HOUSEHOLDERS LISTED ON RENTAL SUBSIDY:
Name
Relationship to Tenant
Gender / Date of Birth
Name
Relationship to Tenant
Gender / Date of Birth
Name
Relationship to Tenant
Gender / Date of Birth
Name
Relationship to Tenant
Gender / Date of Birth
Referral Reasons (Tick all relevant)

Date of last Property Inspection:

Date Legal notices issued:

Tenancy Issues / Government Assistance / Financial Issues
Rental Arrears / Single parent / Financial Difficulty
Tenant Liability / Disability / Gambling problems
Antisocial behavior / Family assistance / Payment arrangements
Overcrowding / Pension / Other Debts
Problematic visitors
Property standards
Internal
Property standards
External
Issues with neighbors

Please provide further details on items indicated above

Family Issues / Abuse/Violence / Legal Issues
Conflict within household / Physical abuse
Change in family structure / Emotional abuse / Convictions/Incarceration of a violent nature.- Past
Parent/guardian moved away / Verbal abuse / Convictions/ Incarceration of a violent nature.- Present
Sexual abuse / Education
Family violence by other household members – DV / DCP involvement
Drug/alcohol abuse

Please provide further details on items indicated above

Disability / Health Issues / Other
Physical / Illness - Physical
Intellectual/learning / Illness - Mental
Psychiatric/Mental Health

Please provide further details on items indicated above

Please briefly expand on information above or add any additional comments:
OTHER SERVICES WORKING WITH HOUSEHOLD:
Name / Organisation / Contact #
Service Provider OFFICE USE ONLY:
Referral Taken By: Date:
Case Worker/ Family Support Worker: Date Received:
Date of Closure:
Written referral acknowledged via fax / email: Date