Homelessness Support/Assertive Outreach Referral Form

Please complete the following form with as much detail as you can to help us process your request in a timely manner. This form is only to be used for non-urgent requests. For any urgent or dangerous issues, please call the City of Kwinana on (08) 9439 0200 or email kwinanaoutreach@stpats.com.au.

Please note that we take your privacy seriously and will not disclose your details to any third party without prior permission.

Referee

Name

Contact Phone Number

Email

Who is making the report?

Referral

Name of Individual (if known)

Gender

Age (approximate if unknown)

Any descriptive features our team should be aware of?

Are any children present?

If yes, Approximate age (of any children present)

In attending this referral is there anything staff should be aware of or are there any safety concerns?

Descriptions of any personal belongings of the individual

Environment

Have you seen this individual on multiple occasions?

If yes, how often?

Receptive to support

Location

Location Address

Location Description

How long at this location? If known

Any dangerous items or items of concern?

Please confirm your identity*

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City of Kwinana kaditj kalyakoorl moondang-ak kaaradj midi boodjar-ak nyininy, yakka wer waabiny, Noongar moort. Ngala kaditj baalap kalyakoorl nidja boodjar wer kep kaaradjiny, baalap moorditj nidja yaakiny-ak wer moorditj moort wer kaditj Birdiya wer yeyi.

The City of Kwinana acknowledges the Traditional Custodians of the land on which we live, work and play, the Nyoongar people. We recognise their connection to the land and local waterways, their resilience and commitment to community and pay our respect to Elders past and present.