Client Referral Form - Coast Shelter

client referral form – specialist homelessness and domestic and family violence support

Coast Shelter’s online referral form is to be completed when requesting a service.

This form can be completed by the client or referring service.

This web form is basic information only and will require further contact to complete the referral. If you are having difficulty completing this form, please phone 02 4326 5395 between 8am-4pm Monday to Friday for assistance.

Type of referral

Self- referralService completing on behalf of a client

Referrer’s details:

If you are filling this form out for yourself, you can leave this section blank.

If you are completing this form as a referral from another service, please provide us information about your service.

Once we receive this form, we will contact the person directly to make a further assessment.

CLIENT details:

Any explainer text to go here?

OTHER FAMILY MEMBERS

Are there other family members requiring support?

If you have children, please provide us their information and include the school they’re enrolled inif applicable.

callback details:

We will get in touch to do a further assessment.

We will be in contact within 48 hours between Monday – Friday.

If this form is sent during the weekend, we will be in contact on the next business day.

Privacy and Confidentiality

Coast Shelter is committed to ensuring that information is used in an ethical and responsible manner and recognises the need to be consistent, careful and thorough in the way that information about clients is recorded, stored and managed.

If you require further information, please contact Coast Shelter on 02 4325 3540

client referral form – specialist homelessness and domestic and family violence support

This form can be completed by the client or referring service.

Type of referral

Referrer’s details:

CLIENT details:

OTHER FAMILY MEMBERS

callback details:

ACKNOWLEDGMENT OF COUNTRY

Contact Details

ADDRESS

PHONE

EMAIL

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