FAMILY VIOLENCE FLEXIBLE SUPPORT PACKAGES - APPLICATION FORMFirst name: Last name: D.O.B: Mobile number: Age: Gender: Does the client identify as LGBTIQ? Is the client currently subject to RAMP involvement? Has the client accessed any other funding sources? (Eg. VOCAT, Utility Relief Grant, Safe at Home, PRAP) If yes, please specify:

Has the applicant received a package previously? If yes, please specify the number of packages previously accessed: If applying for a subsequent FSP package please provide a rationale consistent with the guidelines:

ELIGIBILTY CRITERIA 1. The victim/survivor has a case management plan in place, clearly identifying how the package will support their long term safety, health and

wellbeing; AND

2. The victim/survivor safety and security needs, and independent living goals can be reasonably met through the provision of a FSP; AND

3. The victim/survivor has recently left an abusive situation; OR

4. The victim/survivor is planning to leave an abusive situation or have the perpetrator removed from the home with appropriate legal sanctions in place.

Housing: Current tenancy: Address:

Tenancy type (please select only one): Is the client on the lease? Weekly rent paid by client:

Future tenancy: (Please complete if relevant for delivery) Address:

Tenancy type (please select only one):

Will the client be on the lease? Weekly rent to be paid by client: Start date of tenancy:

Cultural Background: Country of Birth: Year arrived in Australia (if applicable): Language Spoken: Interpreter Required? Residency Status: Cultural Identity: Does the client identify as Aboriginal or Torres Strait Islander? Does Does Does the client identify as culturally and linguistically diverse (CALD)?

Financial: Income Source: Centrelink type (if applicable):

Weekly income: Current debts:

Vulnerabilities: Does the client have a diagnosed mental illness?

If yes please specify: If yes are they receiving treatment?

Is the client currently pregnant? Does the client have substance abuse issues?

If yes, please specify: Does the client have a disability?

If yes please specify:

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DEPENDENTS DETAILS Number of dependent children: CHILD 1. First name: Last name: D.O.B: Age: Country of birth: Address: If other, please specify: Gender: Indigenous Status: Disability: Please specify:

CALD:

Child Protection Involvement:

CHILD 2. First name: Last name: D.O.B: Age: Country of birth: Address: If other, please specify: Gender Indigenous Status: Disability: Please specify:

CALD: Child Protection Involvement:

CHILD 3. First name: Last name: D.O.B: Age: Country of birth: Address: If other, please specify: Gender: Indigenous Status: Disability: Please specify:

CALD: Child Protection Involvement:

To include additional dependent’s pl ease attach Extra Dependents Sheet available from the South Safe website

CHILDREN’S RISK ASSESSMENT Are the children having contact with the perpetrator?

Have any of the children ever witnessed or directly experienced family violence?

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FAMILY VIOLENCE RISK ASSESSMENT RISK FACTORS FOR VICTIM-SURVIVOR YES NO COMMENTS

Pregnancy / new birth* Depression / mental health issue Drug and /or alcohol misuse / abuse Has ever verbalised or had suicidal ideas or tried to commit suicide Isolation

RISK FACTORS FOR PERPETRATORS YES NO COMMENTS Use of weapon in most recent event* Access to weapons* Has ever harmed or threatened to harm victim Has ever tried to choke the victim* Has ever threated to kill the victim* Has ever harmed or threatened to harm or kill children* Has ever harmed or threatened to harm or kill other family members Has ever harmed or threatened to harm or kill pets or other animals* Has ever threatened or tried to commit suicide* Stalking of victim* Sexual assault of victim* Previous or current breach of intervention order Drug and or/ alcohol misuse/abuse* Obsession/ jealous behaviour towards victim* Controlling behaviours* Unemployed* Depression / mental health issue History of violent behaviour (not family violence)

RELATIONSHIP FACTORS YES NO COMMENTS Recent separation* Escalation – increase in severity and/or frequency of violence* Financial difficulties

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HISTORY OF FAMILY VIOLENCE Who is the perpetrator? Approximate date relationship ended: (if known)

Is there an intervention order in place? If Yes, please provide date of expiry:Are Police currently involved? If yes please specify involvement:

Please provide a brief history of the violence:

What was the most recent event?

What was the most serious event?

What has been the impact of this violence on the client (and children if relevant)?

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REQUEST TABLE

Requests Cost $ Outcome Summary of how this request will positively impact the client (Must be directly linked to case plan goals)

TOTAL:

Each item requested must be clearly linked to one of the following outcome areas: (further details provided in the FSP Guidelines)

A. Safety and SecurityB. Capabilities to ParticipateC. Health and WellbeingD. Connection to Culture and Community

For additional items please attach the FSP Extra Request Table document. If requesting furniture, white goods or electrical items please attach the FSP Housing Establishment Order form.

area

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REFERRING AGENCY INFORMATION Organisation: Phone: Address: Case Manager name: Mobile: Case Manager email:

TEAM LEADER ENDORSEMENT Name: Position:

Signature: Date of endorsement:

Please ensure that prior to submitting an application that the following has been completed: (Please tick)

1. The application has been endorsed by a Team Leader.

2. A current case plan is attached (must have been completed within the last 3 months).

3. Quotes/housing establishment order form is attached (if applicable).

4. Verbal consent has been provided by client for FSP Co-ordinators to liaise with external providers for the

purposes of delivery and payment of approved items.

Please refer to the Family Violence Flexible Support Package - Guidelines document for assistance with completing this form. For further enquiries and for the submission of completed FSP applications please email:

FSPapplications@aus.salvationarmy.org

The deadline for all new applications being submitted is close of business Friday. All applications are processed on Mondays (excluding Public Holidays) and are assessed by the panel by Wednesday.

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