Before completing a referral form - Please answer the following questions.

If answering yes please give full details in the section asking about support requirements:

- Have all benefits stopped (nil income) ?

- Has there been an eviction or possession notice issued or is there a court appearance imminent?

- Are Bailiffs due to attend the property within 7 days? (for priority debts only)

- Are there mobility issues or a condition that prevents the person from being able to access the community safely?

- Is there another issue that makes them particularly vulnerable or complex issues that require one to one support?

If you have answered NO, then there is no need to refer, please provide the client with the below flyer and advise

them to attend the drop in service. If these times are unsuitable please ask them to call so we can make alternative arrangements

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FLOATING SUPPORT REFERRAL FORM

NOTE: Please ensure form is completed in full, with as much information as possible by the referrer

Return to : or

First Point, The Orchard, White Hart Lane, Basingstoke, RG21 4AF

APPLICANTS DETAILS
Title: / Applicants Name:
Gender:
Date of Birth:
Ethnicity: / Care Leaver: Y / N
Veteran: Y / N / Nat Ins No:
Economic Status:
Please specify- Working FT, PT, Benefits
Current Address:
Postcode: / Home Tel no:
Mobile Tel no:
Email address:
Type of accommodation: (please specify eg H.A, Private rental etc) / Landlord:
People living at property: / Names and ages
Are there any risks at property? e.g. dogs
Please state if applicant has support from any of the following.
CMHT Drug / Alcohol Housing Probation Children's Services (including EHH)
Please attach any additional information i.e. -CAF Reports, Care Plans,
Support Plans, Reports or give more details below
Please provide support providers details:
Are there any communication needs? (If yes please state)
Any other identified Vulnerability?
Please give full details of the support this person requires:
Referrer's information
Name of Referrer
Date of Referral
Name of Referring Agency
Direct Telephone Number
Mobile Number
Email address

Risk Analysis

YOUpolicy

Whilst we do not seek to exclude any person, fitting the criteria, from our services, we owe it to staff and service users that they receive full support from key agencies who are working with the service users when they take up a service. If this is not the case, it may not be appropriate to offer a service until a guarantee of support is received.

YOUhas a responsibility to assess the risk to staff and service users.

WHY DO I HAVE TO FILL IT IN?

So that we can make sure that your support needs are met.

WHO WILL YOU SHARE THE INFORMATION WITH?

All information given will be treated in the strictest confidence. It will only be shared with those people who need to know about it in order to decide whether or not to offer you accommodation or service, or in order to protect you or others from possible harm.

IF I TELL YOU ABOUT PREVIOUS PROBLEMS, WILL IT STOP YOU FROM OFFERING ME A SERVICE?

We need you to be completely honest about any problems you have had in the past. We will listen to what you tell us and then make a decision about whether we feel we can offer you the support, which you need.

A history of previous will not necessarily stop us from offering a service, Any information disclosed which affect you being offered a place with the service will be discussed with you and the referring agency.

Does the applicant ever behave in the following way?
Prompts: / YES / NO
Regularly shout/swear at others
Throws objects
Insults people through either racist or homophobic remarks
Shoves pushes or punches people
Comments - If yes to any of the above, please give as much detail as possible, list dates, any convictions, nature of events and continue on a separate sheet if necessary.
Criminal Record / Convictions: Has the applicant ever been responsible for any of the following?
Prompts: / YES / NO
Violence which has led to loss of life or serious wounding
Exploitation of others
Sexual offences/incidents
Other Offending Behaviour
Arson
Comments - If yes to any of the above, please give as much detail as possible, list dates, any convictions, nature of events and continue on a separate sheet if necessary.
Criminal Record: Please specify below date(s) of convictions and nature of any sentence, which is not spent under the 1974 Criminal Rehabilitation Act.
Is the applicant at risk from?
Prompts: / YES / NO
Self harm
Exploitation / abuse from others
Social isolation
A dual diagnosis
Self neglect
Alcohol consumption
Substance Misuse
If the answer to any of the previous questions was yes, please give as much details as possible.
Worsening behaviour and known triggers: Does the behaviour tend to get worse?
Prompts: / YES / NO
After consumption of alcohol or other drugs
When in close contact with other people
When in close contact with family/friends
When bored
When Alone
Taking prescribed medication
If YES please list below / YES / NO

Updated JC Feb 2017