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Support Statement
To be completed by the customer/advocate and/or each support worker/health professional separately to obtain an understanding of support needs from both perspectives. A customer may have a person acting of their behalf complete this statement, such as a family member, friend or guardian. Support workers should be professionals, such as an occupational therapist, psychologist or disability carer, providing services on behalf of an organisation or their practice.

A range of housing assistance options are available to help Queenslanders with their housing needs. We need detailed information about any housing needs in relation to a medical condition or disability. Completing this form with accurate and comprehensive details about current barriers and ongoing requirements will assist us to identify an appropriate housing response. A separate Support Statement must be completed for each person in the household who has a medical condition or disability that affects their housing needs. If any of the requested information below is available in an existing assessment, please attach it to this form.

Customer/Advocate:	Support worker/Health professional:	
I,  		I,  		
(name)	(name)	
of _ 			
(address)	(qualifications)	
provide the following details -	at _ 		
	(organisation)	
in relation to myself	of _ 		
	(address)	
on behalf of _ 	_ 		 	_ 		
(name)		
 	_ 	_	provide the following details in relation to the	
(relationship)	customer.	

Full name:	Date of birth:	/	/	
How long have support services been provided?	
Current living location?		
How long living in current accommodation	
Has the customer had difficulty obtaining or sustaining suitable housing? Include the number and length of periods of homelessness and any tenancy issues such as rent arrears, disruptive behaviour or property damage which have impacted the tenancy	

	
How is the medical condition or disability being impacted by the current accommodation?	

	
What housing features of the current accommodation are unsafe or impacting on daily living activities?	
Such as toileting, bathing, grooming, cooking, laundering, mobility.	

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Detail what type of assistance or service is provided by which organisation.
Such as domiciliary nursing care, physiotherapy, occupational therapy, meals on wheels.

Service	Provider	Suburb	Contact person	Telephone	

Detail attempts made to find alternative housing.

Type of accommodation	Suburb	Issue	
			
Detail further information or requirements you feel should be considered in relation to housing needs.

Which of the following housing features are required to assist the medical condition or disability?
Ground floor	Modifications, such as grab rails.	Lowset, maximum steps?  	 Locational need, such as close to hospital or support	Wheelchair access
Requires overnight care
Detail how the selected housing feature/s, or an alternate housing feature, will assist with the medical condition or disability.

What equipment or aids are used to assist mobility inside and outside the current accommodation?
Such as walking frame, wheelchair.

Inside	Outside	
		
Detail any decision-making support arrangements that are in place.
Such as Office of the Public Guardian, Public Trustee, Power of Attorney.

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Support worker/Health professional ONLY:	
Have you observed the customer in their current accommodation?	
How long since you observed the customer in their current accommodation?	
Detail any information in this report which, if released to your customer, might be detrimental to their physical or mental health?	

Declaration
To the best of my knowledge, the information provided in this Support Statement and any attached documentation is true and correct. I understand that I will commit an offence and be liable to a penalty under the Housing Act 2003 if I knowingly provide to the Department of Housing and Public Works false or misleading information that may influence decisions about eligibility for housing assistance and may make the application invalid.

Customer/Advocate:	Support worker/Health professional:	

Signed: _ 	_	/	/	
Signed: _ 	_	/	/	
Telephone:  		Telephone:  		
Email:  		Email:  		
Privacy Notice

The Department of Housing and Public Works is collecting your personal information so we may provide you with housing assistance. To assist you with your housing needs and services, your personal information may be disclosed to partner agencies, service providers, local governments and non-governmental agencies that now, or will, provide you with housing and/or support services. Unless authorised or required by law, your personal information will not be disclosed to any other third party without your consent. More information about the Department’s privacy obligations is available on our website at www.housing.qld.gov.au.