Application Form

The Amber Foundation welcomes referrals on behalf of or from any young person from the age of 16 to 30 years old regardless of gender, sexual orientation, race or ethnicity, gender reassignment, religion or belief and disability.


Unfortunately, we are unable to accept those who have previous convictions for arson, sexual offences, and serious violence. We are also unable to accept those who have a current dependency to alcohol or drugs or those currently receiving substitute prescription medication.

Referrer Details
Referral By

Referrer Details










Reason for Referral
Reason(s) for Referral
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Address Details
Applicant Details
























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Documentation / Access
Does the applicant have any of the following (please tick all that apply):
Applicant Details
Applicant Current Address Details






Next of Kin
Next of Kin Details








Needs and Risk Details
Support Needs Information


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Are you or have you ever received support from or been involved with any of the following (please select all that apply):


Are you in receipt of any of the following benefits (please tick all that apply):


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Risk Details
Risk Information
Do any of the following apply (please tick all that apply):

Further Information
Additional Information


Consent
Consent

I hereby give my permission for the information provided on this form to be given to The Amber Foundation as stated on page 1 of this form.


I also give my permission for the provider to contact any other agencies regarding my support needs, health / psychiatric history and details of any court convictions / reprimands.


I understand that this information will be used by the provider for assessment purposes only and that all written and verbal information concerning this referral will be treated as strictly confidential by Amber.


I understand that, if my application is successful, this information will be held on file and I will have the right of access to it.

I hereby give my permission for any information provided on this and any following forms and assessments to be made available to any third parties that The Amber Foundation deems appropriate, to aid the support and services that I receive from The Amber Foundation and its partners.