Reason for Referral (brief summary): Click or tap here to enter text.

Applicant’s Details

Full name of Applicant: Click or tap here to enter text.

Chosen name (if different): Click or tap here to enter text.

Any other names the applicant may be known as/documented under? Click or tap here to enter text.

Pronoun preference: Choose an item.

Age: Click or tap here to enter text. D.O.B.: Click or tap here to enter text.

Mobile Number: Click or tap here to enter text. Email Address: Click or tap here to enter text.

Yes, it is safe to leave a voicemail: ☐	Yes, it is safe to send a text message: ☐

Cultural Identity

Do you identify as an Aboriginal and/or Torres Strait Islander person?

​​☐​ Yes, Aboriginal person.

​​☐​ Yes, Torres Strait Islander person.

​​☐​ Yes, Both Aboriginal and Torres Strait Islander person.

​​☐​ No.

Do you Identify as Culturally and Linguistically Diverse (CALD)? ☐​ Yes ☐No

Country of Birth: Click or tap here to enter text. Year of arrival (if relevant): Click or tap here to enter text.

Preferred Language: Click or tap here to enter text.

Is an interpreter required? ☐​ Yes ☐No

Children’s Details

Children’s Names	M/F/Other	Age	DOB	Living with whom

Current Housing Situation

Is the applicant experiencing homelessness? Yes ☐ No☐

If yes, which option best describes their situation? Choose an item.

Is the applicant at risk of homelessness? Yes ☐ No☐

Please provide details of their situation: Click or tap here to enter text.

Expected timeframe/date when she will become homeless: Click or tap here to enter text.

Location Details

Please note that Nova is only contracted to support women and children in the provided areas, if her current location is not one of the drop-down options, she will need to be referred to the SHS services associated with her current location. *some exceptions apply. If you would like to discuss these exceptions further, please provide a brief summary.

Suburb applicant is currently residing:

Newcastle Area: Choose an item.	Lake Macquarie Area: Choose an item.

Exception notes: Click or tap here to enter text.

Current known risk factors

Health

Are there any long-term health condition or disabilities that restrict every-day activities? ☐​ Yes ☐No

If yes, please provide details: Click or tap here to enter text.

Is the applicant living with a diagnosed mental illness? ☐​ Yes ☐No

If yes, please provide details: Click or tap here to enter text.

Domestic and Family Violence (DFV)

Is the applicant escaping domestic violence? ☐​ Yes ☐No

If yes, when was the last major incident? Click or tap here to enter text.

Has there been a DVSAT completed? ☐​ Yes ☐No

If yes, what was the score? Click or tap here to enter text.

Please provide a brief summary of situation including notable risks: Click or tap here to enter text.

Drug and Alcohol

Is the applicant experiencing drug and/or alcohol misuse? ☐​ Yes ☐No

If yes, please provide details: Click or tap here to enter text.

Assistance from other Services

Is the applicant (and/or their family) linked in with another SHS service? ☐​ Yes ☐No

If yes, which Service? Click or tap here to enter text.

Contact details: Click or tap here to enter text.

Is DCJ – Child Protection involved? ☐​ Yes ☐No

If yes, which Service? Click or tap here to enter text.

Contact details: Click or tap here to enter text.

Other?

Service: Click or tap here to enter text.	Contact details: Click or tap here to enter text.

Service: Click or tap here to enter text.	Contact details: Click or tap here to enter text.

Service: Click or tap here to enter text.	Contact details: Click or tap here to enter text.

Referrer Details

Referral Service: Click or tap here to enter text.

Worker: Click or tap here to enter text.

Contact Number: Click or tap here to enter text.

Contact Email: Click or tap here to enter text.

Date of referral: Click or tap here to enter text.

The client has provided informed consent to provide this information.

Verbal Consent: ☐​ Yes ☐No

Written Consent (provided via email): ☐​ Yes ☐No