Client information (must be completed for both referral outcome and exiting)
Client name	Click here to enter client name.
Date of birth	Click here to enter date of birth.
Contact phone number	Click here to enter phone number.
Full property address (please include the suburb and postal code)	Click here to enter street number.
Click here to enter street name.
Click here to enter suburb.
Click here to enter town/city.
Click here to enter postcode.

(select and complete this section OR the exiting section)
Client has been successful in their referral to Emerge?	(If no, please complete comments)
Comments (complete only if client is unsuccessful)
Date client is moving in	Click here to enter a date.
Copy of occupancy agreement included?
Rent contribution amount	$ Click here to enter rent amount.
Financial assistance
Is the client applying for financial assistance with rent in advance?
Amount required for rent in advance	$ Click here to enter rent in advance amount.

(select and complete this section OR the referral outcome section)
Date client is leaving the property	Click here to enter a date.
Comments