Form Dh3039 PDF Details

Navigating the complex terrain of social housing can be daunting, especially when it involves assessing an individual's ability to live independently. The DH3039 form serves as a crucial tool in this process, meticulously designed for health professionals or support providers to evaluate and communicate a client’s capabilities in managing life's daily tasks without, or with, external support. This detailed Independent Living Skills Assessment requires careful completion in BLOCK LETTERS using a black or blue pen, ensuring clarity and precision in every section. It marks a pivotal step for clients consenting to undergo this evaluation, a gesture of their trust and a significant move toward securing appropriate social housing. With sections ranging from financial management to personal care, and even social interaction, the form guides the assessor through a comprehensive review of the client's abilities. Additionally, it facilitates a nuanced understanding, allowing space for detailed explanations beyond the constraints of tick boxes and yes/no queries. The DH3039 form is not just a document; it's a bridge between a client's current situation and their potential new home, ensuring that those who are most in need are supported in a manner that respects their independence and dignity. The form must be submitted with accurate and consented information, as it directly informs the social housing provider's decision-making process, making it a critical piece of the puzzle in the journey towards secure and suitable housing.

QuestionAnswer
Form NameForm Dh3039
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other nameshousing pathways independent living skills assessment, Postcode, independent living skills assessment form, NSW

Form Preview Example

Independent Living

Skills Assessment

Please print in BLOCK LETTERS with a black or blue pen

This form is to be completed by the client’s health professional or support provider if the client has consented to the social housing provider’s request for an independent living skills assessment. The Assessment will be used to assist the social housing provider in determining the client’s ability to live independently with, or without, support.

For information or assistance with this form, phone 1300 Housing 24 hours a day, seven days a week. Please mark

relevant boxes with a If you need more room to answer any questions, please include details on a separate page and attach it to this form.

T File number

 

Client reference number

 

 

 

Name of social housing provider

Client consent

I, the undersigned (provide full details)

Title

Mr, Mrs, Ms, Miss

Last name or family name

Given name (s)

Unit/House number

 

Street/Avenue

 

 

 

Town/Suburb Postcode

Phone

 

Mobile

 

 

 

Email address

Do hereby authorise and direct the following agency to provide information (including health information) relevant to my housing application.

Name of health professional/support worker/ carer

Name of agency

Address of agency

Street/Avenue

Town /Suburb

 

Postcode

 

 

 

 

 

Telephone number

I agree that only details which directly relate to my social housing application can be discussed. The release of information from the above agency is for the purpose of clarifying issues relating to my ability to live independently with or without support.

Full name (please print)

Signature

Date

DD / MM / YYYY

 

 

 

 

 

 

 

DH3039 02/12

 

Page 1 of 4

If applicable

Guardian’s full name (please print)

Guardian’s signature

Date

DD / MM / YYYY

 

 

Independent living skills assessment

To be eligible for social housing, the client must be able to sustain a successful tenancy. This means that they must be able to meet the obligations of their tenancy agreement, with or without support.

The following criteria need to be addressed in order to assist the social housing provider to determine whether social housing is the most appropriate housing option for the client’s current housing and support needs.

Section A: Financial management

1.

Based on your professional opinion, does

 

 

Yes

Go to Section B

 

No

Go to question 2

 

 

 

 

the client have the ability to manage their

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

own finances?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Is the NSW Trustee and Guardian or

 

 

Yes

Go to Section B

 

 

No Go to question 3

 

the Public Guardian managing the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

client’s finances?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Is a third party such as a family member

 

 

Yes

 

 

 

No

Go to Section B

 

 

 

 

 

 

 

managing the client’s finances?

Provide details below and go to Section B

Section B: Property care

4.

Based on your professional opinion, does

 

Yes

Go to Section C

 

No

Go to question 5

 

 

 

the client have the ability to maintain their

 

 

 

 

 

 

 

 

 

 

 

 

 

 

home in a satisfactory condition (without

 

 

 

 

 

 

 

support) and not cause property damage ?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Does the client have the ability to

 

Yes

Go to question 6

 

No

Go to Section C

maintain their home in a satisfactory condition with support and not cause property damage?

6.Is the client currently accessing required support services?

Yes

Please list and describe support services being received below

No

Please provide the reasons why the client is not accessing required supports below

DH3039 02/12

Page 2 of 4

Section C: Personal care

7. Based on your professional opinion, does

 

Yes

Go to Section D

 

No

Go to question 8

 

 

the client have the ability to look after

 

 

 

 

 

 

 

 

 

 

 

 

 

 

their basic day-to-day personal care

 

 

 

 

 

 

 

 

 

 

 

 

needs without support?

 

 

 

 

 

 

8.Is a service provider such as Homecare supporting the client in this function?

Yes

 

No Go to question 9

 

 

 

Please list and describe support services being received and go to Section D

 

 

 

Yes

 

No

Go to question 10

9. Is the client being supported in this

 

 

 

function by a carer?

 

 

Provide details below and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

go to Section D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.If the client requires support to perform this function and is not accessing required supports, please provide reasons:

Section D: Social interaction

11.Based on your professional opinion, does the client have the ability to be responsible for their own conduct as well as the conduct of their visitors and not cause or permit nuisance or annoyance?

 

Yes

 

No

 

Please provide details below

 

Please provide details below

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DH3039 02/12

Page 3 of 4

12.In your professional opinion, does the client have the ability to live in close proximity with others?

 

Yes

 

No

 

Provide details below

 

Provide details below

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.Please outline any other issues relevant to the client’s ability to live independently that the social housing provider needs to

take into consideration

The assessment is now complete. Thank you for your cooperation.

Health/support worker name (please print)

Position

Signature

Date DD / MM / YYYY

DH3039 02/12

Page 4 of 4

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Find out how to fill in supported living risk assessment template step 1

2. Once this array of fields is done, proceed to type in the suitable details in all these - Address of agency, StreetAvenue, Town Suburb, Telephone number, Postcode, I agree that only details which, Full name please print, Date, DD MM YYYY, Signature, and Page of.

supported living risk assessment template writing process outlined (stage 2)

3. In this particular step, look at If applicable, Guardians full name please print, Date, DD MM YYYY, Guardians signature, Independent living skills, To be eligible for social housing, Section A To be completed by, How long have you known or worked, the client, Have you seen or worked with the, and Yes. These will have to be completed with greatest awareness of detail.

Stage number 3 of submitting supported living risk assessment template

4. This paragraph comes next with these particular form blanks to consider: In your professional opinion is, Yes, Provide details below and go to, Section B Financial Management, Based on your professional, Is the NSW Trustee and Guardian or, Yes, Go to Section C, Go to question, Yes, Go to Section C, Go to question, Is a third party such as a family, Yes, and Go to Section C.

Is the NSW Trustee and Guardian or, Section B Financial Management, and Go to Section C in supported living risk assessment template

5. As a final point, the following last portion is what you should complete before submitting the PDF. The blank fields in this instance are the next: Section C Property Care, Based on your professional, Does the client have the ability, maintain their home in a, Yes, Go to Section D, Go to question, Yes, and Page of.

maintain their home in a, Yes, and Go to question in supported living risk assessment template

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