SNSS EOI

First Name *

Last Name *

Gender *

Date of birth *

Email AddressPlease provide the complete email address.

Phone number *

Who completed the form? *

Referrer Phone *

Referrer Email *Please provide the complete email address.

Referrer Role *

Name of the person *

Relationship with the Applicant *

Support Person Phone Number *

I confirm that I have the client’s informed consent to refer them to SSI, share their information, and complete this form on their behalf. *

Residential Address *

Street address *

City *

State *

Postcode *

Briefly describe your current situation to accessing primary health care services

Please describe your situation

Do you currently receive any health support services on a regular Basis?

Please provide details of your current health support services

Are you from a Culturally and linguistically Diverse(CALD) background?

Have you had a Refugee experience?

Are you currently experiencing homelessness or at risk of homelessness?

Do you reside in any of the areas listed below? *

Bankstown
Campbelltown
Liverpool
Fairfield
Wollondilly
Camden
Wingecarribee

Preferred language *

Do you require an interpreter?

Preferred Method of Contact *

Preferred Time for Contact

Do you have any specific concerns or requests?

How did you hear about the Health Navigation Support Service?

Please specify *

How would you like to receive the navigator service?

Privacy Statement

SSI collects the personal and sensitive information you provide in this form to respond to yourenquiry, check your eligibility, provide support and services, improve our services, and meetreporting requirements for funding organisations.

We may share your information with government agencies, funders, and service providers whereneeded to support this process or to follow the law.

If you do not provide the requested information, we may not be able to respond to your enquiryor provide support.

For more information about how SSI collects, uses, and shares your personal information, howyou can update your information, or how to remove your consent at any time, please see ourPrivacy Policy: SSI Privacy Policy.

I have read and understood the above information. I provide my consent to the collection, use, and disclosure of my information as explained above. I understand I am free to remove consent at any time. *

YesNo

I understand completion of this Expression of Interest does not guarantee acceptance into the Service. Acceptance will be determined based on meeting eligibility requirements and availability of services. *

YesNo

Thank you for your interest. Unfortunately, we are unable to proceed with your expression of interest as we did not receive consent. Please feel free to reach out if you have any questions or need further information.