default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. Suspected case of homelessness form Please complete the following questions to notify the relevant officers within Council of a suspected case of homelessness. This information will then be communicated to appropriate service providers to assist the individual. (This question is mandatory) Please describe the address or location:Please ensure you include enough information for someone to return to the same location. (This question is mandatory) Suburb: Please choose... Avonsleigh Bayles Beaconsfield Beaconsfield Upper Bunyip Bunyip North Caldermeade Cardinia Catani Clematis Cockatoo Cora Lynn Dalmore Dewhurst Emerald Garfield Garfield North Gembrook Guys Hill Heath Hill Iona Koo Wee Rup Koo Wee Rup North Lang Lang Lang Lang East Longwarry Maryknoll Menzies Creek Modella Monomeith Mount Burnett Nangana Nar Nar Goon Nar Nar Goon North Nyora Officer Officer South Pakenham Pakenham South Pakenham Upper Rythdale Tonimbuk Tooradin Tynong Tynong North Vervale Yannathan Other: Other: (This question is mandatory) Were they on Council land? Yes Not Sure No (This question is mandatory) Please summarise the environment: You can choose more than one Bushland Parkland Residential dwelling Commercial area Other: (This question is mandatory) Were there any accessibility issues? Large locked fence Away from walking paths/roadway None Other: (This question is mandatory) Were there any potential risks at the location? Dog Broken glass / other dangerous waste Violent/threatening behaviour of people in vicinity Violent/threatening behaviour of individual Abandoned building Vehicle traffic Flooding Bushfire None Other: (This question is mandatory) How many homeless people are there at this location? (This question is mandatory) Gender of individual(s) Male Female Other Don't know (This question is mandatory) Approximate age of individual(s) Child Youth Adult Elderly Don't know Other: (This question is mandatory) Did they have children with them? Yes Not sure No (This question is mandatory) Please provide any other information about the person(s) Signs of alcohol use Signs of drug use Signs of physical disability for which they need assistance Signs of mental health issue Signs of illness Nothing else Other: (This question is mandatory) Did you interact with them? Yes - please tell us what you talked about -> No Please enter your comment here: Other Comments (This question is mandatory) Please provide your name and contact information in case we have any further questions.This information will only be used internally by Council if we need to clarify something. Your name: Preferred contact (phone/email): Thank you. Please click on Submit to send us the report. The report will be sent to Megan Clarke, Social Policy and Projects Officer - Affordable Housing. Submit Please confirm you want to clear your response? Exit and clear survey
