Tenancy Referral – Caseworker

(To be completed by Caseworker/Keyworker)

Applicant's details

Applicant’s Name

Referring Hospital/Clinic

Psychiatrist's details

Name

Contact Phone

Case Manager/Key worker details

Name

Phone

Email

General Practitioner's details

Name

Phone

Applicant's Medical information

Primary Diagnosis

Secondary Issues

Current Medication list:

Name

Dosage

Frequency

If there are more medications, please list them below (please add dosage and frequency for each medication)

Any history of

If yes, please provide further details of the above and any other relevant behavioural traits

By submitting this form the person I acknowledge that the person I am referring consents to the release of any information about them, as required by the Administration of Emmaus Community, in order to assess this application for tenancy and assist with living in the Community. All personal information is securely disposed of if applicant doesn’t join Emmaus Community. I have made it clear that this is independent community living and that they must be able to live independently to reside at Emmaus.