ABOUT THE INDIVIDUAL BEING REFERRED

HIV SUPPORTED ACCOMODATION ELIGIBILITY CRITERIA (SELECT ONE OR MORE) REFERRAL FOR NSW HIV SUPPORTED ACCOMMODATION (PORT JACKSON) DATE OF REFERRAL

NAME:

DOB:

GENDER:  MALE  FEMALE

MEDICARE NUMBER:

ADDRESS:

STATE: POSTCODE

PHONE:

COUNTRY OF BIRTH:

IDENTIFY AS: ABORIGINAL  YES  NO TORRES STRAIT ISLANDER  YES  NO IF YES, WOULD THEY LIKE AN ABORIGINAL HEALTH WORKER?  YES  NO PREFERRED LANGUAGE:  ENGLISH  OTHER: INTERPRETER REQUIRED:  YES  NO  NSW Resident  HIV Positive  HIV related health needs which prevent independent living  HIV related complex needs which prevent independent living  HIV related brain impairment (e.g. HAD, PML)

SUPPORT REQUIREMENT  Psychosocial support  Nursing care CURRENT HOUSING SITUATION  No permanent accommodation  Private tenancy / sharing  Supported (aged care, AOD, HIV etc)  Other (clarify)

HOUSING NEED (SELECT ONE OR MORE)  Short term respite & stabilisation  Medium to long term  Live alone with support  Shared living with support WHAT IS THE INDIVIDUAL’S: Viral load ______CD4 count ______Date of test ______IS THE CLIENT AWARE OF THE REFERRAL

 YES  NO IF NOT, WHY? PORT JACKSON ELIGIBILITY CRITERIA: (Tick relevant)  Pathways Housing Priority Status  History of homelessness / failed tenancies  Unable to live independently without support  Current housing situation is damaging to health CASE MANAGER AGREES TO: (must tick all to be eligible)  View the Port Jackson property and attend the sign up with client  Visit the client’s home regularly, including attending inspections with the Tenancy Manager at SGCH  Support client with tenancy issues such as rent arrears, neighbour disputes, property maintenance and tribunal advocacy  Support client for the duration of their tenancy within the PJSHP  Alert HIV Supported Accommodation Coordinator of any issues that may threaten client’s tenancy (unauthorised occupants, prolonged absence from the property, neighbour disputes, property damage) so they can work with SGCH in rectifying the issue early REFERRER DETAILS ALTERNATIVE CONTACT Name: Organisation: Address:

Postcode: Phone: Email: Other comments: The Coordinator will call the referrer to discuss the referral. This may take several minutes. If you would rather someone else be the contact for this eg the case manager, list their details below: NAME: POSITION: PHONE: Email completed form to [email protected]