(This form is to be used to give the Department of Housing /Regional Service Provider your permission to refer you to a STEP provider and for Department of Housing / Regional Service Provider and the STEP provider to share information about your tenancy)

Tenant Name(s):

Tenant Address: ______

______

(Please tick one box)

Tenant(s) agrees to referral (tenant completes Part A)

Tenant(s) does not wish to participate (tenant completes Part B)

Part A – to be completed by tenant(s)

(Please tick each box)

/ I agree to the STEP referral and give consent for the Department of Housing / Regional Service Provider and the STEP Provider to share information relating to my tenancy.
/ I understand that all information disclosed under this consent will be treated in the strictest confidence. The information will be used to assist in developing an agreed plan to support my tenancy.
/ I understand this consent can be withdrawn at any time by informing the STEP Provider or my Housing Services Officer.
/ I understand this authorisation will cease if the referral is not accepted or upon completion of the program provided by the STEP Provider.
/ The purpose of this form has been explained to me.

Tenant1 Signature: ______Date:______

Tenant2 Signature: ______Date:______

Tenant3 Signature: ______Date:______

Housing Services Officer: Go to part C (turn overleaf)

All personal and in-confidence information accessed as part of the Support and Tenant Education Program will be managed in accordance with the provisions of Public Sector Commissioner’s Circular 2009-29: Policy Framework and Standards for Information Sharing between Government Agencies – Standards for Managing Personal and In-Confidence Information.

Part B – to be completed by tenant(s)

I do not wish to participate in STEP. The following information has been provided and explained to me:

(Please tick each box)

/ STEP is being offered to help support my tenancy
/ What STEP is about and how I could benefit from participation.
/ STEP is voluntary and free.
/ An individual plan to support my tenancy would be developed through STEP.
/ I can withdraw from STEP at any time.
/ I may consent to being referred to STEP at a later date by telling the Housing Services Officer.
/ The purpose of this form has been explained to me.

I do not wish to participate in STEP for the following reason(s)

Tenant1 Signature: ______Date:______

Tenant2 Signature: ______Date:______

Tenant3 Signature: ______Date:______

Part C – to be completed by Housing Services Officer

This form has been signed after full explanation of STEP to the tenant

Officer Name______

Department of Housing Office

/ Regional Service Provider:______

Position: ______

Signed:______Date:______

For Part A:

  1. Copy of this form to be provided to tenant
  2. Copy of this form to be placed in tenant’s personal file
  3. Copy of this form to be uploaded in TRIM
  4. Copy of this form and STEP Referral Form to be sent to Senior Officer

For Part B:

Tick this box if the tenant does not wish to sign this form

Record reason(s): ______

  1. Copy of this form to be placed in tenant’s personal file
  2. Copy of this form to be uploaded in TRIM
  3. Copy of this form to be sent to Aboriginal Housing Services, Contract Management ()