Created Mon, October 3rd 2022
Date of birth
Emergency contact phone
Do you have children?
Do you have a partner?
Have you been involved with DCP (past or present)?
What is your cultural identity?
Do you have an income?
Can you provide an income statement or payslip?
How much do you get and when do you receive this?
Date of next pay?
Do you have any outstanding debts?
Why are you accessing accommodation?
Where are you staying now and when do you need accommodation?
Have you ever stayed in transitional accommodation before?
Where do you ultimately want to live?
Have you ever used alcohol or other drugs (past or present)?
Date of last AoD use?
Triggers for using?
Do you have outstanding police, court or justice matters?
Do you have any criminal convictions?
Do you have Legal representation?
Do you have any difficulties with physical or mental health issues?
Have you ever been diagnosed by a doctor with a mental health issue?
Have you been prescribed any medication?
What are your early warning signs if becoming unwell?
What are your triggers?
What strategies do you use to keep well?
How can staff best support you?
Do you have a support network for Mental health?
What do you do during the day usually?
Is there anything you think we should know about you that will help us help you?
You will receive the opportunity to volunteer at AYLA Inc. What area would you like to
give your time to?
Do you have any pre-existing medical condition that would prevent you from doing
Parent / Guardian (complete if under 16 years old)
I agree to let my child complete the following hours of volunteer work
Tick this checkbox:
Lock form (make all empty, non-signature fields un-fillable)
Our Mission: to aid communities, and assist individuals to
Reception & Head Office
10 McKinnon Street
Cockburn Central WA 6164
08 9414 7286
Mon-Fri (10:30am -
Mon-Fri (9.00am -
Sat (9.00am - 3:00pm)
Sun (11:00am -
You Matter Relief
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