REFERRAL – The VA Centre

Please use the form below to submit an online referral to our support services and supported housing.

We will contact you with reguards to the status of your application. Upon acceptance to our services we will require proof of ID and relevant documentation which we will request at the initial interview.

Please fill out the form fully to prevent delays in the application

Referrer's Name

First

Last

to The order.

Phone

Name of the person you are referring *

Age

The client has

Additional Information

Current Housing Situation

Brief Background of Mental Health History

Medical Information

Support Requirements

Useful Contacts

Funding Details

I give my consent for the information that I have given to be shared internally and between The VA Centre and relevant agencies in order to access accommodation and services in relation to my identified needs.

It has been explained to me that this information will be held on a database, will remain confidential, and will not be shared with any other agency without first seeking my permission.

I understand the only exception to this will be where there are serious concerns about personal safety or others, e.g., contemplation of suicide/self-harm, threats of violence, or a court order.