Family Support Program Referral Form Enquiries: info@houseofsadaqa.org.au Referrer – Name(Required) First Last Email(Required) Enter Email Confirm Email Contact Number(Required)Organisation or Company NameClient DetailsName(Required) First Last Date of Birth(Required) Day Month Year Phone Number (Please ensure this number is active)(Required)Address(Required) Street Address Address Line 2 City State / Province / Region Post Code Country of Origin Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Languages SpokenGender Female Male Marital Status Single Married Divorced Widowed Number of Adults(Required)Number of Children (Please provide age and Gender to help with getting groceries that are age approperiate)(Required)Briefly provide details of client's circumstances (Pick more than 1 if applicable)(Required) Victim of domestic violence Homeless (or at risk, staying at a friend’s, temporary accomodation) Mental health Disability Financial crisis Single mother/father Refugee/asylum seeker Child protection issues Unemployed Natural disaster Victim of crime/robbery Other Provide details of client's circumstances (including factors leading to financial crisis and why client cannot afford items themselves.)Client Essential RequirementsPlease select from the following list according to client needsItems Required(Required)Please use extra comments below for quantities or other items not listed. Refrigerator Washing Machine Queen Bed Queen Mattress Queen Bed Sheet & Blanket Set (includes pillows) Single Bed Frame Single Mattress Single Bed Sheet & Blanket Set (includes pillows) Dining Table Set 3 Seater Couch 2 Seater Couch Cookware Set (Pots, Pans, Utensils) Crockery Set (Cutlery, Drinking Glasses, Plates, Bowls) Microwave Oven Vacuum Cleaner Pedestal Fan Kettle Toaster Laundry Services Groceries Halal Meat Pack Toilet Paper Clothing Transport Services Social Services Referral Counselling Services Pest Control Service Lawn & Garden Services Handyman Services Other (Please specify below): Extra comments(Required)Do you need multiples of any of the above items or specify a size.Eligibility & Zakat Assessment(Required)Do you currently have accommodation?Are you currently receiving any financial assistance?If Yes, from where?Do you believe you may be eligible for Zakat? Yes No Unsure (If unsure, we will assess eligibility based on our Zakat checklist) Do you identify with a particular religious faith or spiritual practice? (This helps us provide culturally appropriate support) No specific affiliation Islam (Muslim) Christianity Hinduism Buddhism Other Risk & Accessibility Needs – Do you have any immediate safety concerns?Do you have any accessibility needs (e.g., interpreter, mobility support)?Upload ID, income statements/payslips, utility bill, housing or caseworker support letter.(Required) Drop files here or Select files Max. file size: 20 MB. Please provide any documents you have available.Terms & Conditions (To be discussed with the client)• House of Sadaqa provides assistance based on availability of resources and eligibility criteria. • We reserve the right to assess and prioritize cases based on urgency and need. • Clients must ensure they or a designated individual are available to receive deliveries. • House of Sadaqa is not responsible for removal of any unwanted or existing household items. • All items provided are donations and not for resale. • Misrepresentation of circumstances may result in discontinuation of support. • House of Sadaqa may contact the referrer or client for follow-up and impact assessment. • Acceptance of assistance indicates agreement to these terms. Consent & Declaration(Required) I consent to House of Sadaqa collecting and using my personal information for the purpose of providing support services I understand that my information may be shared with relevant service providers if required for assistance I declare that the information provided in this form is true and correct to the best of my knowledge. Select AllCAPTCHADate MM slash DD slash YYYY
