PHYSICAL IMPAIRMENT FLOATING SUPPORT SERVICE
Level 10 West Wing, Moorfoot Building, Sheffield, S1 4PL
Telephone: 0114 2037209 Fax: 0114 2037217
E Mail: /
Client Information Sheet
1. Referrer Details
Referred by: / Date of Referral:
Worksite: / Contact Number:
Key Worker: / Contact Number:
Social Worker: / Contact Number:
2. Service User Details
Full Name: / Date of Birth:
Full Address:
Postcode: / Mobile Number:
Landline Number: / CareFirst ID:
National Insurance: / Housing Reference:
3. Emergency Contact Details
Full Name:
Full Address:
Landline Number: / Mobile Number:
Relation To Client
4. Next of Kin Details (If different from above)
Full Name:
Full Address:
Landline Number: / Mobile Number:
Relation To Client
5. GP Details (If Applicable)
Full Name:
Full Address:
Landline Number: / Mobile Number:
6. Additional Service User Information
Gender: / Male / ☐ / Female / ☐ /
Personal Budget: / Yes / ☐ / No / ☐ /
English Speaking: / Yes / ☐ / No / ☐ /
Registered Disabled / Yes / ☐ / No / ☐ /
Registered with GP: / Yes / ☐ / No / ☐ /
7. Religion
Atheist / ☐ / Buddhist: / ☐ / Jewish: / ☐ /
Christian / ☐ / Hinduism: / ☐ / Muslim: / ☐ /
Sikh: / ☐ / Do not wish to state: / ☐ / Other: Specify Below / ☐ /
8. Marital Status
Single / ☐ / Married / ☐ / Civil Partnership / ☐ /
Co-Habitating / ☐ / Widow / ☐ / Do not wish to state: / ☐ /
Other:
Please Specify / ☐ /
9. Sexual Orientation
Heterosexual/Straight / ☐ / Lesbian / ☐ / Gay Man / ☐ /
Bi- Sexual / ☐ / Do not wish to state: / ☐ / Other: / ☐ /
10. Ethnicity
White: British / ☐ / White: Irish / ☐ / White: Any Other Background / ☐ /
Black or Black British African / ☐ / Black or Black British Caribbean / ☐ / Black:Any Other Background / ☐ /
Asian or Asian British: Indian / ☐ / Asian or Asian British: Pakistani / ☐ / Asian or Asian British: Bangladeshi / ☐ /
Asian or Asian British: Other / ☐ / Mixed: White & Black African / ☐ / Mixed: White & Black Caribbean / ☐ /
Asian or Asian British: Other / ☐ / Mixed: White & Black African / ☐ / Mixed: White & Black Caribbean / ☐ /
Mixed: White & Asian / ☐ / Mixed: Any Other Background / ☐ / Other Ethnic Origin: Chinese / ☐ /
Other Ethnic Origin: Other / ☐ / Gypsy/ Romany/ Irish Traveller / ☐ / Other: Specify Below / ☐ /
11. Primary Language
Arabic / ☐ / Bengali / ☐ / British Sign Language / ☐ /
Chinese Cantonese / ☐ / Chinese Mandarin / ☐ / English / ☐ /
Farsi / ☐ / French / ☐ / Kurdish / ☐ /
Other / ☐ / Pashto / ☐ / Polish / ☐ /
Punjabi / ☐ / Romanian / ☐ / Slovak / ☐ /
Somali / ☐ / Spanish / ☐ / Urdu / ☐ /
12. Nationality Category
UK National
(Skip Section 13) / ☐ / UK National:
Returning to UK / ☐ / EEA- Czech Republic / ☐ /
EEA- Estonia / ☐ / EEA- Hungary / ☐ / EEA- Lithuania / ☐ /
EEA- Poland / ☐ / EEA- Slovakia / ☐ / EEA- Bulgaria / ☐ /
Non EEA / ☐ / Croatia / ☐ / Other: Specify Below / ☐ /
13. Immigration Status
Limited leave to remain / ☐ / Temporary Visa / ☐ / Spouse Visa / ☐ /
Student Visa / ☐ / Work Visa / ☐ / Other: Specify Below / ☐ /
14. Referral Agency (If applicable)
Adult Social Care / ☐ / Archer Project / ☐ / Catch 22 / ☐ /
Children & Young People Social Care / ☐ / Community Mental Health Teams / ☐ / Disc / ☐ /
Domestic Abuse Advice Line / ☐ / Hospital Discharge Facilitator / ☐ / Police / ☐ /
Probation Service / ☐ / Shelter Advice Line / ☐ / Tenancy Relations Officer / ☐ /
Turning Point Rough Sleepers / ☐ / Other: Specify Below / ☐ /
15. Employment Status
Full Time (24 Hours or more per week) / ☐ / Part Time (23 Hours or less per week) / ☐ / Self Employed / ☐ /
Full Time Student / ☐ / Government Training or Work Programme / ☐ / Long Term Sickness or Disabled / ☐ /
Unemployed: Seeking Work / ☐ / Unemployed: Not Seeking Work / ☐ / Retired / ☐ /
Other: Please Specify / ☐ /
16. Unemployment Period (If Stated in Section 15.)
1 – 3 Months / ☐ / 3 – 6 Months / ☐ / 6 – 12 Months / ☐ /
1 – 2 Years / ☐ / 2- 5 Years / ☐ / Over 5 Years / ☐ /
17. Income Range
£0 - £6000 / ☐ / £6000 - £12,000 / ☐ / £12,000 - £20,000 / ☐ /
£20,000 - £30,000 / ☐ / £30,000+ / ☐ / Over £300 Per Week / ☐ /
18. Housing Status
Not Known / ☐ / Any other Temporary Accommodation / ☐ / Approved Probation Hostel / ☐ /
Bed & Breakfast / ☐ / Children’s Home or Foster Care / ☐ / Direct Access Health / ☐ /
Foyer / ☐ / Home Office Asylum Support / ☐ / Hospital / ☐ /
Housing Association: General Needs / ☐ / Housing Association: Tenancy / ☐ / Housing for Older People / ☐ /
Living With Family / ☐ / Living With Friends / ☐ / Local Authority General Needs Tenancy / ☐ /
Mobile Home or Caravan / ☐ / Other / ☐ / Owner Occupation / ☐ /
Owner Occupation: Low Cost Home / ☐ / Placed / ☐ / Prison / ☐ /
Private Sector: Leasing / ☐ / Private Sector: Tenancy / ☐ / Residential Care Home / ☐ /
Rough Sleeper / ☐ / Short Life Housing / ☐ / Supported Housing / ☐ /
Tied Housing or Rented with Job / ☐ / Women’s Refuge / ☐ /
19. Household Type
One Person- Female Applicant / ☐ / One Person- Male Applicant / ☐ / Couple with Dependent Children / ☐ /
One Person- (M) With Dependent Children / ☐ / One Person- (F) With Dependent Children / ☐ / All Other Households / ☐ /
Start Date: If Applicable:
20. Primary Needs
Older Person with Support Needs / ☐ / People with Mental Health Problems / ☐ / People with Physical or Sensory Disabilities / ☐ /
People with Learning Disabilities / ☐ / Single Homeless with Support Needs / ☐ / People with Alcohol Problems / ☐ /
People with Drug Problems / ☐ / Offenders or People at Risk of Offending / ☐ / Young People at Risk / ☐ /
Young People Leaving Care / ☐ / People at Risk of Domestic Violence / ☐ / Homeless Families with Support Needs / ☐ /
Teenage Parents / ☐ / Rough Sleeper / ☐ / Traveller / ☐ /
Complex Needs / ☐ / Primary Client Type Not Known / ☐ / Secondary Client Type Not Known / ☐ /
21. Secondary Needs (If applicable)
Older Person with Support Needs / ☐ / People with Mental Health Problems / ☐ / People with Physical or Sensory Disabilities / ☐ /
People with Learning Disabilities / ☐ / Single Homeless with Support Needs / ☐ / People with Alcohol Problems / ☐ /
People with Drug Problems / ☐ / Offenders or People at Risk of Offending / ☐ / Young People at Risk / ☐ /
Young People Leaving Care / ☐ / People at Risk of Domestic Violence / ☐ / Homeless Families with Support Needs / ☐ /
Teenage Parents / ☐ / Rough Sleeper / ☐ / Traveller / ☐ /
Complex Needs / ☐ / Primary Client Type Not Known / ☐ / Secondary Client Type Not Known / ☐ /
22. Disability Details
23. Brief Description of Support Needs
Please forward completed form to:
Tracey Deenah or Wendy Armswood:- Physical Impairment Floating Support
Level 10- West Wing, Moorfoot Building, Sheffield, S1 4PL
Telephone: 0114 2037209 Fax: 0114 2037217
E Mail:
1
Amended Referral Form V1