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Guardian Housing Limited – Referral Form
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Referral Form
REFERRAL FORM FOR SUPPORTED ACCOMMODATION
Step1
Step2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
SECTION 1 – REFERRAL AGENCY DETAILS
Referral Agency
Phone
Email
Reason for Referral
SECTION 2 - APPLICANTS DETAILS
Name
Address
Date of Birth
Gender
Contact Number
NINO
Benefit Status
Immigration Status
Entry Date to UK
Ethnicity
Next of Kin / Relationship
Next of Kin Address
Next of Kin Contact Number
SECTION 3. PREVIOUS ADDRESS HISTORY (INCLUDING SUPPORTED ACCOMMODATION)
Address
Dates / Duration
Occupany Type
Reason for Leaving
Address
Dates / Duration
Occupany Type
Reason for Leaving
Address
Dates / Duration
Occupany Type
Reason for Leaving
SECTION 4 – APPLICANT MEDICAL BACKGROUND / HISTORY
Social Worker / CPN / Probation Officer/ Other
GP Name / Address - if applicable
Has Client ever been detailed / sectioned under the Mental Health Act? / Details
Physical Health History
Present medication and / or Treatment
Criminal Convictions / Community Order incl DATES
Other Relevant Information
SECTION 5 – SUPPORT NEEDS (You MUST tick YES to at least 5 support needs to be considered and accepted for supported accommodation)
Tenancy failure or losing short term accommodation
YES
NO
Rough Sleeping
YES
NO
Ongoing issues with drugs and alcohol
YES
NO
Money Management and Budgeting
YES
NO
Access to Local Services
YES
NO
Reduce Social Isolation
YES
NO
Skills to eat healthily
YES
NO
Developing Interpersonal Skills
YES
NO
Ability to manage Personal Hygiene
YES
NO
Maintaining your Tenancy, avoiding Eviction
YES
NO
Improve Social and Community Networks
YES
NO
Applying for the correct Benefits
YES
NO
Unplanned Hospital Admissions
YES
NO
Re-establishing Family Links
YES
NO
Accessing Drug and Alcohol Services
YES
NO
Access to Health Services
YES
NO
Maintain a Healthy Lifestyle
YES
NO
Managing and Maintaining Nutrition
YES
NO
Reduce Risk of Debt
YES
NO
Being Appropriately Clothed
YES
NO
Risk of Domestic Abuse
YES
NO
Having Access to Food Banks
YES
NO
Access Voluntary Services
YES
NO
Accessing and Engaging in Work
YES
NO
Ongoing Health Conditions
YES
NO
Application for Council Residence
YES
NO
Risk of Self Harm
YES
NO
Risk of Harm from Others
YES
NO
Developing Problem Solving Skills
YES
NO
Accessing and Engaging in Voluntary Work
YES
NO
Risk of Offending and Re-Offending
YES
NO
Liasing with Probation Services
YES
NO
Risk of Long Term Unemployment
YES
NO
Accessing and Engaging in Training
YES
NO
Accessing and Engaging in Education
YES
NO
SECTION 6 – RISK ASSESSMENT - *RISK ASSESSMENT (WE WILL NOT ACCEPT REFERRALS WITHOUT A CURRENT RISK ASSEESSMENT) PLEASE PROVIDE INFORMATION BELOW (OR SEND CURRENT RISK ASSESSMENT)
DOES APPLICANT HAVE A HISTORY OF BEHAVIOURAL ISSUES - IF SO PLEASE INDICATE RISK LEVEL ASLOW/MEDIUM/HIGH AND POTENTIAL TRIGGERS / POTENTIAL VICTIMS
VIOLENCE, AGGRESSIVE BEHAVIOUR
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
SELF-HARM / SUICIDE / MENTAL HEALTH FORMAL DIAGNOSIS
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
DRUG / ALCOHOL MISUSE
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
CHILD PROETECTION ISSUES
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
SEXUAL OR SCHEDULE 1 OFFENCE
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
CRIMINAL CONVICTIONS / OFFENCES
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
SELF-NEGLECT / NEGLECT OF OTHERS
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
ANTISOCIAL BEHAVIOUR
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
DAMAGE TO PROPERTY
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
ARSON
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
ANY OTHER INFORMATION
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
IS THE APPLICANT AT RISK OF HARM FROM OTHERS? IF YES PLEASE STATE BY WHOM AND PROVIDE DETAILS
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
SECTION 7 – AUTHORISATION - APPLICANT / REFERRAL AGENCY
I give my consent to the disclosure of this information for the purpose of finding accommodation and to the disclosure of any supplementary information attached for housing purposes I give my permission for the outcome of this referral to be explained to the referral agency I agree to participate in a support package including support planning and assessment
I would / would not like a copy of this referral (Delete as appropriate)
YES
NO
SECTION 8 - SUPPORTING DOCUMENTATION / ADDITIONAL INFORMATION
Additional Information
FILE ATTACMENTS
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PLEASE NOTE: CAPITA HOUSING IS AN EQUAL OPPORTUNITIES HOUSING PROVIDER. HOWEVER, WE RESERVE THE RIGHT TO REFUSE REFERRALS WITH A HISTORY OF ARSON (INSURANCE REGULATIONS) AND SEX OFFENCES AGAINST CHILDREN.
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