Housing Expression of Interest Form
Participant Details
First Name
Last Name
Date of birth
Person Completing this Form
Relationship to participant
Participant
Family Member
Support Worker
Social Worker
Other
First Name
Last Name
If other:
Mobile Number
Email Address
Housing Interest Details
Does the participant have a NDIS plan?
Yes
No
Does the participant have a support coordinator?
Yes
No
Participants Current Living Situation
Dependent living with family
Independent living
Independent living with family
Independent with friends/others
Specialist Disability Accommodation (SDA)
Aged Care
Support Residential Services (SRS)
Community Residential Services (CRS)
Other
If Other
Which Melbourne suburb would the participant like to live in?
First Option
Second Option
Third Option
Ideally when would the participant want to move into a house?
Less than 6 months
Between 6 months and 2 years
Between 2 years and 5 years
Greater than 5 years
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