Full Name Date of Birth Gender MaleFemale Address Street City State Postcode Phone Number Email Address Preferred Language Spouse/Partner's Name (if applicable): Children's Names and Ages (if applicable): Referred By SelfCommunity MemberOrganizationOther Referrer's Name (if applicable): Referrer's Contact Number Relationship to Referrer Settlement Needs Type of Assistance Required: (e.g., Housing, Employment, Education, Health Services, Language Classes, Legal Assistance, Social Support) Specific Needs or Requests Preferred Schedule for Services: Any Immediate Concerns or Urgent Needs Date of Arrival in Australia Visa Type Country of Origin Previous Residency (if applicable):
Health Information Current Health Conditions Medications Health Insurance Provider Education and Employment Highest Level of Education Previous Occupation Current Employment Status Skills or Qualifications Support Network in Australia: (e.g., Friends, Relatives, Community Groups) Other Services Currently Accessed: I consent to the collection and use of my personal information by the Eritrean Australian Community and Settlement Support Network Program for the purpose of providing settlement support services. I agree to the terms and conditions of the settlement support services.
