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 Violence YesNo Drug/Alcohol Abuse YesNo Attempted Suicide YesNo 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.
