Annexe A

Youth Homelessness Single Gateway – Referral to Families Working Together

All sections should be completed or this may delay the progress and allocation of your referral.

Name of Referrer: / Date of Referral:
Referrers agency: / Referrers telephone number:
Referrers email address:
Young Person's name: / ICS # (if known):
Social worker (If Known):
Young Person's DOB: / National Insurance #:
Address: / Telephone number:
Cause of Homelessness
Parental/Carer/Guardian eviction
Breakdown of current supported accommodation placement
Other / Additional details:
Initial Prevention Work
Please confirm details (and dates) of initial discussion with Parent/Guardian /Carer/ and any discussions with wider friends and family:
Date of discussion: / Method of discussion: / Face to face
Telephone
Name:
Address: / Telephone number:
Content of discussion/outcomes:
No discussion has taken place. / Reason:
Housing Options Explored
Please confirm specific options discussed, and the young person’s preferred option.
Supported Lodgings
YP’s preferred option / Options discussed/available:
Supported Accommodation
YP’s preferred option / Options discussed/available:
Private Rented Accommodation
YP’s preferred option / Options discussed/available:
Social Housing
YP’s preferred option / Options discussed/available:
Homeless Legislation explained? Yes
No
Homeless Application taken? Yes
No
Single Accommodation application Yes
completed? No / Details:

Please ensure you answer every question. Failure to do so may slow the progress of your referral.
To check a box, please double click on the box

Youth Homelessness Single Gateway – Referral to Families Working Together

All sections should be completed or this may delay the progress and allocation of your referral

Previous Accommodation and Finances
Please detail if the young person has ever lived independently and if so what happened:
Young person has never lived independently
Please detail what income the young person has:
Young person has no source of income.
Is the young person registered disabled? Yes No
Is the young person in receipt of DLA/PIP? Yes No
Opportunities for Future Work
Please provide details of any employment, education or training that the Young person is currently attending and/or any opportunities that could assist in a more positive outcome?
Please confirm that you have discussed what prevention work will be carried out to prevent or resolve the young person’s homelessness:
Families Working Together support explained Young person willing to accept support
Risk Assessment – for visit to the Young Person's Home Address
Risk / Details
Young person / someone in the household has a history of violence/ aggressive behaviour?
Details: / No risk identified
Not known
There are regular visitors to the accommodation who pose a risk to the young person or to visiting staff
Details: / No risk identified
Not known
Young person / someone in the household has an historical or current issue with alcohol or substance misuse
Details: / No risk identified
Not known
Young person/someone in the household has a history of self-harm or suicide attempts
Details: / No risk identified
Not known
Any other risk issues or concerns?
Details: / No other concerns

Note: Please ensure that within each section of the above risk assessment a box has been ticked and provide as much detail as possible.

Please ensure you answer every question. Failure to do so may slow the progress of your referral.
To check a box, please double click on the box