Form: Copelands Intake Created Sat, July 27th 2024 Details Name 1 Name Date of birth 1 Date of birth Age 1 Age Phone number 1 Phone number Email address 1 Email address Emergency contact 1 Emergency contact Emergency contact phone 1 Emergency contact phone Do you have children? 1 Do you have children? Do you have a partner? 1 Do you have a partner? Have you been involved with DCP (past or present)? 1 Have you been involved with DCP (past or present)? What is your cultural identity? 1 What is your cultural identity? Please select Anglo Australian Aboriginal/Torres Strait Islander Unknown Other Not specified Income Status Do you have an income? 1 income_status_check Do you have an income? Please specify 1 Please specify Please select Centrelink Newstart Awaiting payment Wages from employment Disability Allowance Other Centrelink Can you provide an income statement or payslip? 1 Can you provide an income statement or payslip? How much do you get and when do you receive this? 1 How much do you get and when do you receive this? Date of next pay? 1 Date of next pay? Do you have any outstanding debts? 1 Do you have any outstanding debts? Accommodation Background Why are you accessing accommodation? 1 Why are you accessing accommodation? Where are you staying now and when do you need accommodation? 1 Where are you staying now and when do you need accommodation? Have you ever stayed in transitional accommodation before? 1 Have you ever stayed in transitional accommodation before? Where do you ultimately want to live? 1 Where do you ultimately want to live? Please select Independently Long Term Shared Long Term Group Setting Alcohol & Other Drugs Have you ever used alcohol or other drugs (past or present)? 1 drugs_check Have you ever used alcohol or other drugs (past or present)? Please Specify 1 Please Specify Date of last AoD use? 1 Date of last AoD use? Previous supports? 1 Previous supports? Triggers for using? 1 Triggers for using? Legal Information Do you have outstanding police, court or justice matters? 1 Do you have outstanding police, court or justice matters? Do you have any criminal convictions? 1 Do you have any criminal convictions? Do you have Legal representation? 1 Do you have Legal representation? Health & Mental Health Do you have any difficulties with physical or mental health issues? 1 health_check Do you have any difficulties with physical or mental health issues? Please specify 1 Please specify Have you ever been diagnosed by a doctor with a mental health issue? 1 diagnosis_check Have you ever been diagnosed by a doctor with a mental health issue? Please specify 1 Please specify Have you been prescribed any medication? 1 health_medication_check Have you been prescribed any medication? Please specify 1 Please specify What are your early warning signs if becoming unwell? 1 What are your early warning signs if becoming unwell? What are your triggers? 1 What are your triggers? What strategies do you use to keep well? 1 What strategies do you use to keep well? How can staff best support you? 1 How can staff best support you? Do you have a support network for Mental health? 1 Do you have a support network for Mental health? Other What do you do during the day usually? 1 What do you do during the day usually? Is there anything you think we should know about you that will help us help you? 1 extra_help_check Is there anything you think we should know about you that will help us help you? Please specify 1 Please specify You will receive the opportunity to volunteer at AYLA Inc. What area would you like to give your time to? 1 You will receive the opportunity to volunteer at AYLA Inc. What area would you like to give your time to? Please select None Reception Admin Food Bank Sausage sizzle Grant Writing Food collection Cafe Gardens Online services(website/social media) Do you have any pre-existing medical condition that would prevent you from doing volunteer work? 1 volunteer_exempt_check Do you have any pre-existing medical condition that would prevent you from doing volunteer work? Please specify 1 Please specify Parent / Guardian (complete if under 16 years old) I agree to let my child complete the following hours of volunteer work 1 I agree to let my child complete the following hours of volunteer work Signature Reporter Type name: Draw signature: Tick this checkbox: Lock form (make all empty, non-signature fields un-fillable) SUBMIT
