SOLAS CYMRU - REFERRAL FORM
Please be honest and open in your responses – we need the information to assess whether we can meet the applicants needs and to be aware of any risk issues in order to ensure the safety of the applicant and the safety of residents and our premises in general
1. Applicant Details:
Title / Mr / Mrs / Miss / Ms / Other:Forenames
Surname
N.I Number
D D M M Y Y
Sex / M / F / Date of BirthIf applying to a young persons service please put the name of parent/guardian
Title / Mr / Mrs / Miss / Ms / Other:Forenames
Surname
Address
Applicant’s point of contact (telephone or mobile or another contact point where the applicant can be reached:
2. Details of referral agency
Name of referring agency:Name and contact details of person making referral (including address, telephone number and e-mail)
Relationship to applicant and period you have known them for:
Is the applicant subject to any legal attachments e.g. Licence, Schedule, Section, Appointeeship, etc.
If so please give details:
With the applicant’s agreement please attach any care plans and risk assessments or any other information you feel is relevant to the application and list please list any attachments below. If you cannot provide them now please give details of when they will be supplied:
3. Housing Information:
Current Address and type of housing (e.g. council, housing association, friends, relatives, prison, hospital etc):When did the applicant move there? (month and year):
If the applicant is a tenant - have they got any rent arrears?
Previous address 1 / Previous address 2
Information relevant to young people: Have the applicant ever been in care (foster care or a residential placement)? – If so please give details
Type of care e.g. residential or foster placement:Length of stay i.e. dates (month and year):
4. Medication issues
Is the applicant on any medication at the moment – either to do with the applicant’s physical or emotional health YES / NO
If so could you let us know what medication?If the applicant is registered with a Doctor can you tell us his/her name and the address of the surgery?
5. Financial circumstances
Type of Income: (please tick)
Income SupportJob Seekers Allowance
Incapacity Benefit / Disability Living Allowance
Other
Please Specify:
Does the applicant have any loans, debts or other financial issues that we should be aware of?
6. Support
As well as the agency involved in making this application are there any agencies currently involved in providing support to the applicant. Please provide details (e.g. social worker, probation service, day care, Community Mental Health Team, voluntary organisations etc.)
Agency name / Contact person / Address of agency / Telephone numberThere are a number of issues which the applicant may feel has that they want/need support to address. Please give us your views:
They don't need to give a lot of information – at this stage we just want their broad views about what they think are their main support needs and would like them to complete the questions below in the following way:
ð If they have any support needs in relation to the area/heading tick the box
ð If the box has been ticked say how big the issue to them - by circling a number from 0 to 10 – i.e. lower numbers indicate that the applicant feels they have high needs and want a lot of support on the issue
a) LIVING SKILLS (PRACTICAL ISSUES TO DO WITH MANAGING A HOME) like paying bills, sorting out benefits, budgeting, cooking and cleaning, understanding the tenancy issues and dealing with the landlord, making sure the home is in good repair, getting any alterations done, feeling confident about sorting things out.
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10High / Medium / Low / No issues
b) SOCIAL NETWORKS – Does the applicant want support to meet new people and find new groups of friends or have they lost touch with people or want/need to resolve some difficulties in previous relationships (e.g. family, friends, children etc.). Do they lack confidence in this area in general?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10High / Medium / Low / No issues
c) SUBSTANCE MISUSE – Does the applicant want help to manage any addictions that are impacting on their life and general wellbeing such as:
(Please tick the box if any are relevant to you and then circle one number below)
· smoking
· drinking too much alcohol
· an over reliance on prescribed medication
· other drugs
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10High / Medium / Low / No issues
d) PHYSICAL HEALTH PROBLEMS – has the applicant got any physical problems that they are finding it difficult to cope with and that they feel they support to get the help you need and to manage the issues generally :
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10High / Medium / Low / No issues
e) EMOTIONAL HEALTH ISSUES – does the applicant have support needs relating to a diagnosed mental health condition, other undiagnosed mental health issues such as depression or a lack of confidence or self esteem that can make them feel vulnerable, isolated or unhappy
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10High / Medium / Low / No issues
f) MEANINGFUL USE OF TIME E.G. TRAINING, EDUCATION AND EMPLOYMENT, HOBBIES AND INTERESTS – Does the applicant need support and help to address any of the following:
· Employment
· Education
· Training
· Using community and leisure facilities
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10High / Medium / Low / No issues
Personal Responsibility - Why is the applicant applying to us at this point in their life – give us some idea below of what they feel are the main support issues and why they want to tackle them now?
7. Assessing and managing issues that may put the applicant risk or that may present a risk to others
a) Has the applicant committed violent/sex offences?
Yes No Don’t know
b) Does the applicant have a history of aggressive/threatening behaviour?
Yes No Don’t know
c) If under 18 – Is the young person subject to Child Protection Arrangements?
Yes No Don’t know
If you have answered yes to any of the questions above please give details in the box below.
Type & Context of RiskCurrent offending behaviour
Previous offending behaviour
No previous history (tick)
If an ex offender - are there any restrictive licence conditions (Please give details)?
Are there any Court Orders in place which would limit where the applicant could live or go (please give details)?
Is the applicant subject to Multi Agency Public Protection Arrangements (MAPPA) (tick)
Yes No Don’t know
Is the applicant defined by the authorities (Police, Probation, Community Safety Partnership) as a Prolific Priority Offender (PPO)
Yes No Don’t know
Using the definitions set out below please complete the tables below by placing a tick where relevant:
· None: Make this judgement and tick this box where the question has no relevance to the person concerned.
· Low: Make this judgement and tick this box where the person may have experience of this area but it was some time ago and/or the issue has been resolved or it is a current issue but experienced at a low level and in your view there is no medium term or immediate risk stemming from the issue.
· Medium: The issue is current or in the recent past, is felt to be problematic and significant by the client, and is a significant issue in your opinion and presents reasonable level of risk.
· High: The issue is current or in the recent past, is felt to be problematic and significant by the client, and is a significant issue in your opinion and presents a risk which is of a pressing and immediate nature.
b) Risk of serious harm involving
To children / To the public* / To a known Adult / To self / To staff / Damage o property e.g. arsonHigh
Medium
Low
None
(*If you have filled in the public column above please complete the table below)
Amongst the public or known adults are there specific risks to:
Young adults / Older people / Women / Any minority group / Neighbours / Other
High
Medium
Low
Please give details on the areas you have ticked
c) Are there factors that increase the risk of harm to self or others (tick relevant box)
(√) / Provide details e.g. length of time, whether it is a past or present issues, treatment, contact with agencies/professionals, other support, client viewsMental Health
Drugs
Alcohol
Racist or other discriminatory behaviour
d) Does the applicant feel personally unsafe or at risk of exploitation by anyone at the current time – this may be financial, sexual, due to harassment/bullying?
Yes No Don’t know
If you have answered yes please provide brief details:
In order to assess the needs of the applicant and make a decision as to whether we can offer them accommodation and support we may need to approach other individuals and organizations to discuss the applicant’s needs. The applicant’s signature below indicates that they are happy for us to do this.
Applicant
I agree for my information to be shared within Solas and for my needs to be discussed with organizations with whom I have had contact in respect of my support and housing needs.
I am aware of the information given on this form and feel it is an accurate view of my current needs and situation
Applicant’s signature: Date:
Referral agency
I confirm that the detail provided on this form is to the best of my knowledge true and correct
Referrer signature: Date:
Appendix Two
SOLAS CYMRU – GEORGE STREET
REFERRAL INFORMATION SHEET
TO BE COMPLETED BY SOLAS STAFF WHEN THEY GO THROUGH THE APPLICATION FORM WITH THE APPLICANT AND THE REFERRAL AGENCY
The purpose of this form is to gather further detail. Staff completing the form should:
· Alter the marks on the original form under the support needs section where it becomes apparent that the initial scores are not accurate
· Add further factual detail in note form on this sheet and should reference the point under which they are making additional notes in the left hand column e.g.6a),7 c) etc. Staff should use additional sheets as necessary.
Applicants name:Point
Names of member/s of staff completing the form:
Signatures of staff:
Date:
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