CLIENT REFERRAL FORM

Preferred Worker Characteristics

What do you wish to see in your Support Worker?
At Journey Community Connections, We recognize the significance of matching the right staff member to meet your needs and consider several factors such as personality, language, culture and skill requirements.

We encourage and support you to be involved in the process of matching your needs with the right staff. We can also support you to access an advocate of your choice to support you in this process.
Gender

MaleFemaleNo Prefference
Personality Type
Any Specific Languages?
Any Cultural or Religion?
Do you Require specific needs, skills and Knowledge within your Support Worker?
Do you require any Intrusive Supports?
Do you have any Specific needs which require Monitoring and/or daily support by appropriately trained Workers?
What specific Training may be required to Provide Support Services to you?
Do you have any more notes in relation to Potential Support Worker Matching?
Please sign below to indicate your consent and agreement to the details set out in this client intake form above.
If you do not consent/agree please specify
Signed for and on behalf of Journey Community Connections Pty Ltd ABN 98 666 694 293 (Journey Community Connections), by:
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Signed by the Client
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Signed by the Representative
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Approved By: The Board of Journey Community Connections Pty Ltd Approval Date: September 2025
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About You

About You

Preferred Worker Characteristics