Client Intake

Please note the this form can only be completed by the applicant or the parent/guardian of the applicant requiring an appointment or service and can NOT be completed by a third party on behalf of another person.

Staff/Volunteer assisting? *

Date Assistance Requested *

Referred by/ heard about us? (Name of GP, Friend, Organisation, social media etc.) *

Client First Name *For children/youth under 16 years the parent/guardian must put their name in as primary client.

Client Last Name *

New Client? *

YesNo

Date of birth *

Clients full name for counselling if under 16 years Please note Parent/Guardian become primary client on file for clients under 16 years old.

Street Address ? *If no permanent address write current place staying or last known address

Suburb *

Postcode *

Primary Address? *

YesNo

Current Address? *

YesNo

Identifies as *

Gender - Other

What are you pronouns?

Phone Number *

Safe to leave message? *

YesNo

Email Address

Safe to email

YesNo

Country of birth? *

Year of arrival, if not Australia?

Main language spoken at home? *

Any other languages?

Are you currently working? *

Main income source? *

Awaiting new benefit? *

Yes No

Student/Trainee *

YesNo

If yes, enrolled in

Relationship status? *

Currently receiving NDIS (National Disability Insurance Scheme) *

YesNo

Current or previous Australian Defence Force (ADF)? *

YesNo

Do you have a physical disability which affects your mobility? *

Yes No

If yes, please ask if assistance if required to access the centre

Do you have adequate/safe housing? *

YesNo

If no refer to Hume Housing 9722 4300 and/or PSFaNS 4987 1331

Names of children under 18 years

Please enter and complete all sections for each child under 18 years old (Surname, given name, gender, date of birth, relationship, who are the clients or reside where the client resides.

Leave blank if no children

Do you have children under 18 years? *

Yes - please complete section below for each child (child 1 = C1, child 2 = C2, etc)No - Go to section 2

C1 - Surname

C1 - given name

C1 - Gender

MaleFemaleOther

C1 - DOB

C1 - Relationship

C1 - Identifies as

C2 - Surname

C2 - given name

C2 - Gender

MaleFemaleOther

C2 - DOB

C2 - Relationship

C2 - Identifies as

C3 - Surname

C3 - given name

C3 - Gender

MaleFemaleOther

C3 - DOB

C3 - Relationship

C3 - Identifies as

C4 - Surname

C4 - given name

C4 - Gender

MaleFemaleOther

C4 - DOB

C4 - Relationship

C4 - Identifies as

C5 - Surname

C5 - given name

C5 - Gender

MaleFemaleOther

C5 - DOB

C5 - Relationship

C5 - Identifies as

C6 - Surname

C6 - given name

C6 - Gender

MaleFemaleOther

C6 - DOB

C6 - Relationship

C6 - Identifies as

Child protection order

Section 2

The Yacaaba Centre is partially funded by the Department of Community and Justice (DCJ). The DCJ collects information for data purposes which is encrypted and anonymous. By completing this form you agree that the information may be included in Government National Data Collection which will not be identifiable and the information used will only be for statistical purposes. If you have any queries please contact the Centre on (02) 4984 2176

Please choose main reason *

If other, please describe

Prior Mental health diagnosis *

YesNo Prefer not to say

Have you had a period of homelessness? *

YesNo

If yes? *

Time since last permanent address? *

Living arrangements *

Dwelling *

Tenure *

Conditions of occupancy *

Notes/comments