1. Applicant's Details Full Name as per NRIC * Date of Birth * Gender * Male Female Citizenship * Marital Status - select Marital Status - Single Married Divorced Separated Widowed Languages Spoken Ethnicity * Street Address Postal Code * Rental/Owned 1/2/3/4/5 room (if others please specify)Type of housing Contact No. * EmailPreferred day/time for phone callService(s) RequestedFinancial Assistance (Project Love)CounsellingInformation & ReferralOther. Consent For Referral . * I have been informed by the Referrer, on the purpose of this referral to New Life Community Services to receive casework and counselling services. . * I consent to disclosure of personal information recorded on this form, to be accessed by staff of New Life Community Services, and to be contacted for the purpose above mentioned. . * I understand that records of my personal information are protected under the Personal Data Protection Act 2012 of Singapore, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may request to view records of my personal information or revoke this consent at any time.SignatureAcknowledged date Referrer Contact (if applicable)Name Of ReferrerRelationship With ApplicantIf applicableOrganizationContact No.EmailReferral Source Self Referral Individual MPS School CEFC SSA SSO Government Agencies Internal Services Others If you have indicated 'Others' for Referral Source, do specify the source below.Other Referral SourcesDescription of situation and assistance requiredReferrer Signature Date BackgroundHas the client sought professional help previously?Yes No Name of Organization/sDate of InterventionDesription of concerns and reasons for counselling referralUpload Supporting DocumentsFinancial Assistance – Project Love Eligibility Criteria: - Household with children below 25 years old. - Housing type: HDB -rm & smaller - Household's per capita income: $1200 or less (after CPF) - If Singaporean, already approached Social Service Office (SSO) Fill the field below with the information below: I) Full name II) Age III) Relation to Applicant IV) Monthly Income (before CPF) V) Occupation VI) Employer / School (indicate level) VII) Nationality (SC / SPR / WP Please specify)Family Details Please tick all that appliesIssues leading to financial difficultiesMedical conditionUnemploymentNew addition to familyIncarceration of breadwinnerDeath of adult caregiverSignificant loss of incomeIn process of divorce/separatedMental health conditionsRetrenchment How long can you survive on your savings?Financial sustainability - select Financial sustainability - Less than 1 week 1 week to 1 month 1 month to 3 months 4 months to 6 months More than 6 months I) Organization II) Assistance Received III) Amount IV) From (mm/yyyy) V) To (mm/yyyy) Current financial assistance received (Type of assistance & duration)Other Remarks: CounsellingArea(s) of ConcernsSchool RelatedLearning DifficultiesBehavioural IssueSocial DevelopmentEmotional DevelopmentMental Health IssueCareer/Work RelatedFamily circumstances Save Cancel
