Referral Application for NSW HIV Supported Accommodation Program
CHECKLIST FOR ELIGIBILITY FOR RESPITE ACCOMMODATION
 client is a resident within NSW, and
 is infected with HIV, and
 HIV is the significant factor in the client’s need for respite accommodation
 client is eligible for social housing and has applied for Pathways Housing (unless client has a
permanent housing option they will be returning to)
CHECKLIST FOR ELIGIBILITY FOR LONGER TERM ACCOMMODATION
All the above plus
 has a cognitive or physical impairment which precludes them from living independently, or
 has complex needs directly related to their HIV infection which prevents independent living.
 client needs support to live independently
 client is eligible for social housing and has applied for Pathways Housing (unless referring to Yaralla)
*IMPORTANT* CHECK BEFORE SUBMITTING THE FORM:

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The client meets the eligibility criteria (listed above)
All sections have been filled out to the best of the referrer’s knowledge
The consent form is signed, completed and attached
The client has been given the NSW Health Consumer & Carer Rights & Responsibilities leaflet
A current care/support plan, no more than 3 months old, is attached
Confirmation from Housing Pathways that client has applied / is approved for housing is attached
ASSESSMENT
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■
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■
The co-ordinator will contact the referrer to discuss the client’s situation and needs in more detail
Following the review of the application, the client may be asked to meet with the co-ordinator for
further assessment.
Both the referrer and the client will be notified of the outcome of the application as soon as a
decision has been made.
This application will remain active for three months, once referrer is notified of its receipt.
All information provided will be treated in confidence. Submitting a form doesn’t guarantee admission to
a supported accommodation facility. Admission to Yaralla requires additional medical assessment.
Admission to The Villa requires a referral to Adahps for case management.
All applications and supporting documentation should be emailed to the HIV Supported Accommodation
Coordinator. Alternatively fax them marked “Confidential” to 9382 8611.
CONTACT
Jo Spengeler
HIV Supported Accommodation Coordinator
Ph:
9382 8602 or 0413 457 417
Fax: 9382 8611
Email: jo.spengeler@sesiahs.health.nsw.gov.au
ADAHPT\Adahps\Adahps Services & Programs\Accommodation\Application Forms\current form v24
NSW HIV Supported Accommodation Program
Referral Application Form
REFERRER
Date:
Name of Referring
Organisation
Contact Person
Alternate Contact
Person
Phone
Email
Address
CLIENT
Surname
First Name
Contact Number
Current Address
Age
Date of Birth
/
/
Medicare Number
Sex
Male
Female
Intersex
Transgender
Single
Married / De facto
Not stated
Separated
Widowed
Divorced
Marital Status
ETHNICITY
Ethnicity
Country of Birth
Language spoken at
home
Aboriginal or Torres
Strait Islander:
Nationality
Residency
Status
Yes
No
Personal Alternative Contact
Name
Address
Phone
HOUSING
Living
Arrangements
Please circle
Independent housing: private rental / social housing / sharing / owner occupier
Supported: aged care / HIV / AOD / mental health / disability / DV
Homeless: sleeping rough
couch surfing
emergency accommodation
Boarding House
caravan park
hospital
………………….
Previous address
Details of any pets to be housed
REASON FOR HOUSING
Supported Accommodation Application Form v23
Page 1
Short term Respite & stabilisation:
 Stanford House and /or  Bobby Goldsmith House
Med to Long term Unable to live independently – live alone:
 Port Jackson Program
Med to Long term Unable to live independently & cognitively impaired – shared living:  The Villa  Yaralla
PATHWAYS (Social Housing Waiting List)
Is the client on the
Pathways housing
waiting list?
Yes
Awaiting decision date of application :
/
/
No Your client is only eligible for a) Yaralla or for b) respite on the condition that
they have a permanent housing option to return to after their stay there
What is the client’s Pathways T number?
T
Waiting list type
Standard
Priority
confirmation letter attached
INCOME
DSP
Aged Pension
Awaiting Confirmation
Working: FT
PT
Newstart
Carers Pension
Family Allowance
Student: FT
PT
Incapacitated Newstart
Sole Parent
None
SUPPORT
Name of client’s case manager:
Ph:
If no case manager, who will provide support while client is in supported accommodation?
Is the client being supported by an Allied Health/NGO service?
Name
Yes
Organisation
No
Phone
TREATING GP & HIV SPECIALIST
Service
Name of GP
Address
Treating HIV
Specialist
Organisation
Contact Name
Phone
Address
HIV, HEPATITIS and TB HEALTH
When was the client diagnosed HIV Positive
Diagnosing
Date:
/
/
Clinic:
practitioner
Last known T Cell & Viral load results
T Cell
Viral load
Is the client on medication for their HIV (eg Anti-Retroviral Therapy, Bactrum)
Test date:
Yes
/
/
No
If yes, how long have they been taking this medication?
Additional health conditions?
Hepatitis
A
TB
No
B
Yes
C
Treatment:
Current
Treatment:
Supported Accommodation Application Form v23
Page 2
MENTAL HEALTH
Does the client have a mental illness?
Yes
No
Has there been a diagnosis made?
Yes
Date:
Don’t know
/
/
Don’t know
No
What is the diagnosis?
Is the mental illness due to HIV or pre-existing?
Is client on medication for mental illness?
Pre existing
Yes
Don’t know
HIV-related
Don’t know
No
Diagnosing practitioner?
Who is currently providing treatment?
COGNITIVE HEALTH
Does the client have a cognitive impairment?
Has there been a cognitive assessment?
Yes
Yes
Date:
Don’t know
No
/
/
No
Don’t know
If there has, who conducted it?
Is the cognitive impairment due to HIV or pre-existing?
Pre existing
HIV-related
Don’t know
Who is currently providing treatment?
BEHAVIOUR & SOCIAL INTERACTION
Is there any history of aggression or domestic violence?
Yes
No
Does the client display inappropriate behaviour?
Yes
No
Does the client have an obvious network of friends and supports?
Yes
No
ALCOHOL & OTHER DRUGS
It is important that accommodation facility staff are aware of any previous or current use to ensure effective working
with the client and ensure the safety of the client & other residents
DRUG
DATE LAST USE
FREQUENCY
Does the client consider this a problem
Alcohol
/
/
Yes
No
Marijuana
/
/
Yes
No
Methamphetamine
/
/
Yes
No
IVDU
/
/
Yes
No
Methadone
/
/
Yes
No
Opiates
/
/
Yes
No
Other
/
/
Yes
No
LEGAL
Is the client under any legal orders?
TYPE
Yes
No
DETAILS INCLUDING CONTACT
Mental Health Order
Probation & Parole
Financial Management Order
Supported Accommodation Application Form v23
Page 3
Guardianship Consent
Apprehended Violence Order
Public Health Order
Respite Accommodation: Explain how HIV is the significant factor in the client’s need for respite
accommodation
Longer Term Accommodation: Explain why the client needs support to live independently and how their
complex needs directly relate to their HIV. Why is your client’s current situation not appropriate?
Supported Accommodation Application Form v23
Page 4
CHECKLIST 
The client meets the eligibility criteria (listed on front page)
All sections have been filled out to the best of the referrer’s knowledge
The consent form is signed, completed and attached
The client has been given the NSW Health Consumer & Carer Rights & Responsibilities leaflet
A current care/support plan, no more than 3 months old, is attached
Confirmation from Housing Pathways that client has applied / is approved for housing is attached
Your name: ____________________________________ Your Agency: ____________________________
Your Signature: ________________________________
Date __________________________________
All applications and supporting documentation should be marked confidential and faxed or emailed to:
Attention:
Jo Spengeler
HIV Supported Accommodation Coordinator
Ph: 9382 8602 Fax: 9382 8611
Email: jo.spengeler@sesiahs.health.nsw.gov.au
Supported Accommodation Application Form v23
Page 5
Client consent to disclose information for referral to HIV Supported
Accommodation
Federal and NSW legislation requires that we obtain your written permission for the purposes of consent.
I, (client’s full name) ____________________________ give permission to
(referrer’s name and agency) ___________________________________to disclose the information
contained in this application about my health and circumstances to the HIV Supported Accommodation
Coordinator for the purposes of my supported housing application.
I also consent to the information contained in the attached application being disclosed to Housing NSW,
Community Housing Providers and (other agencies involved) ________________________________
____________________________________ for the purpose of addressing my accommodation needs.
I understand that my information will not be shared without my prior knowledge. This permission is given
on the understanding that information will not be used by staff for any other purpose.
I have been informed and understand that:
 my personal information might be used for statistics, record audits, research and data collection. No
identifying information about me will be used;
 the HIV Supported Accommodation Coordinator will contact Housing Pathways agencies to discuss
my Housing Pathways application
Legal limitations to confidentiality may potentially require a staff member to disclose your information
to a third party without your consent where:
1. the staff member is concerned that you may harm yourself or others;
2. a child or young person is at risk;
3. a Court of Law instructs us to disclose your information.
I understand and give my consent to the disclosure of information as outlined above.
________________________________
Signature of Client
Date
/
__________________________________
Signature of Staff member
/
Or
Signature of person on behalf of client
________________________________
(If under Protective Order or Power of Attorney/ proof required)
Date:
/
/
Case Management Plan: HIV Supported Accommodation Program
Client name:
Client Signature
NEEDS TO BE
TARGETED
Case Management
Care Coordination
Health Monitoring and
Health Maintenance
Medication Compliance
Date:
/
/
STRATEGIES
What needs to be done? Where
possible detail small achievable and
measurable tasks for clients
Case Manager:
Review Date:
/
RESOURCES AND ACTION PLAN
Who works on clients needs?
List contact details here
/
OUTCOMES
Can add a column for performance
indicators or be more specific about
outcome measures
NEEDS TO BE
TARGETED
Emotional Support
Financial Support
Ensure Carers are
Supported
Safety and Security
Social and Daily
Activities
STRATEGIES
RESOURCE AND ACTION PLAN
OUTCOMES
NEEDS TO BE
TARGETED
Drugs and Alcohol
Legal
Accommodation
 Current tenancy
issues
 Exit Strategy out of
supported
accommodation
Management of Difficult
Behaviour
Neuropsychological
needs
(following neuropsych
assessment)
STRATEGIES
RESOURCE AND ACTION PLAN
OUTCOMES