Positive Pathways

REFERRAL FORM

(PLEASE DO NOT COMPLETE AREAS IN ITALICS - FOR USE BY HUB ONLY)

Client ref / Date received by Hub

The below checklist is an essential criteria in order for us to be able to consider the referral. The referral cannot go ahead without this information.

Please complete this checklist once the referral is completed.

Provided (Please Tick)
Does the client Live / Wish to live in Leeds
Does the client have a local connection to Leeds?
Housing Need
Mental Health
FACE Risk - Or other suitable and appropriate risk assessment
Equal Opportunities
Service / Worker Preference - checked with client

Please return the form to:

Positive Pathways

Community Links

Bank House

150 Roundhay Road

Leeds LS8 5LJ

Fax no 0113 200 9178

SELF / REFERRAL FORM – Positive Pathways

SECTION ONE: Client Details:
Full Name:
Contact address: / Post Code:
Status: / Council¨ RSL¨ Private¨ Owner Occupier¨ Other: Please specify ______
Date of Birth: / Contact number:
E-mail:
Do you have a Leeds Homes application? / YES / NO / Membership Number:
Referring Agency details completing on behalf of client (not to be completed for self-referrals):
Name:
Team/Agency address: / Post Code:
Contact Number: / Email:
Do you (the referrer) wish or need to be involved during our assessment? / YES / NO
Next of Kin / Emergency Contact Details:
Name: / Relationship to Client:
Address: / Post Code:
Contact Number: / Email:
SECTION TWO: Housing Need - Please provide details of your housing support need:
If you answer Yes to any of the below questions you must provide additional details in the boxes
Homeless or rough sleeping: / YES / NO / Add Detail:
Sofa surfing or staying with friends: / YES / NO / Add Detail:
Threat of eviction or home being repossessed: / YES / NO / Add Detail:
Issues concerning debts/arrears: / YES / NO / Add Detail:
Unable to return to your property: / YES / NO / Add Detail:
In severely unsuitable accommodation (e.g. poor condition or too large or small): / YES / NO / Add Detail:
Threatened with violence / abuse or harassment where you are living: / YES / NO / Add Detail:
Have you been offered a move, and if so do you have a moving date? / YES / NO / Add Detail:
If you are currently residing in a Hostel / Supported Accommodation:
Is there a discharge date / YES / NO / If yes, when?
Additional Housing Related Needs: Please provide details of any other housing needs
Is a move needed? If yes, add detail:
SECTION THREE: Mental Health - (Formal diagnosis is not required to access this service)
If you answer Yes to any of the below questions you must provide additional details in the boxes
Please provide details of any mental health support needs / Please give further details
Does the client consider themself to have issues connected to mental health? / YES / NO
If you have answered No to the above question then we may not be the right service for you.
Is the mental health need considered to be long and enduring? / YES /NO
Is the need considered to be serious and complex? / YES /NO
Are there issues connected to substance misuse? / YES / NO
Additional Mental Health Details: Please provide any additional information that may support your referral
SECTION FOUR: Physical health
If you answer Yes to any of the below questions you must provide additional details in the boxes
Are there issues connected to physical health? / YES / NO
Is there a disability? / YES / NO
Learning Disability:
If you answer Yes to any of the below questions you must provide additional details in the boxes
Is there a learning disability? / YES / NO
Is the client on the autistic spectrum? / YES / NO
SECTION FIVE: Other services involved / Please give further details
Is the client on the Care Programme Approach? / YES / NO
If yes, who is CPA co-ordinator (please include contact details) / YES / NO
Details of any dependants living with the client:
Please give details of any other Agencies or professionals involved in supporting the client within the past 6 Months
Worker / service / Name / Contact Number

Carer or significant other

Psychiatrist

GP
CMHT
Social Worker
Drug / Alcohol Services
Probation
Other :
Is the person at risk of disengaging from services? / YES / NO
Additional Details:
Preferred Language (Please complete this section for all clients)
Is an interpreter required? / YES / NO
Requires specific contact method: (Please circle)
Audible Alert / Email / Letter
SMS / Telephone / Text Relay
Tactile Alert / Visual Alert / Did not want to state
Communication Support Required: (Please circle)
Does Lip Reads / Uses Hearing Aid / Citizen Advocate
Legal Advocate / Alternative Communication Skill / Uses Communication device
Uses cued speech transliterator / Deafblind Intervener / Uses Electronic note taker
Uses Lipspeaker / Uses manual note taker / Uses Personal Communication Passport
Uses British Sign Language / Uses Makaton Sign Language / Uses Speech to text reporter
Uses telecommunications device
Requires information in specific format: (Please circle)
Email / Contracted Grade 2 Braille / Easyread / Electronic audio format
Electronic downloadable format / Makaton / Moon Alphabet / Uncontracted Grade 1 Braille
Audio Cassette Tape / Compact Disc / Digital Versatile Disc / USB
Information Verbally / Written information in Large Font
Referrals to this service are allocated to the next available agency for assessment, unless a particular agency or worker speciality is required.
Please tick which service is required (please leave blank if no preference):
Does the referred person have a Service Preference?
Community Links / Leeds MIND / Leeds Irish Health & Homes
St Anne’s / Touchstone / LCC Homeless Support Team
LCC IMPACT Team
Does the referred person have a worker/specialist preference?
Black African Caribbean: / South Asian: / Drug & Alcohol:
Female: / Male: / Parent & Child:
SECTION SEVEN: Information and Consent
Declaration:
As far as I know the information I have given on this form is true. I understand that providing false information may result in housing and support being withdrawn.
I confirm that I have discussed this referral with those concerned and they have agreed to their data and all relevant information collected in order to complete this referral to be shared with all parties involved.
Access to information:
I understand that in order to continue with this application information from other sources may be sought. By signing below I give permission that any information which will help complete this application will be provided.
I also give consent to those concerned with this application to share information that is relevant to help it be completed.
Signed for / by or on behalf of applicant:
Name ______Signature ______Date ______

Self Referral Risk Assessment

Your perception of risk (please rate the following):

Risk/Level

/

None

/

Low

/

Medium

/

High

/

Not known

Of suicide

/ / / / /

Of deliberate self harm

/ / / / /

Of accidental self harm

/ / / / /

Of self-neglect

/ / / / /

Related to physical condition

/ / / / /

Of abuse/exploitation by others

/ / / / /

Of violence/harm to others

/ / / / /

Of relapse

/ / / / /

Of offending

/ / / / /

Is the person being referred subject to any of the following? (Tick as appropriate)

/

MAPPA ¨

/

MARAC ¨

/

CAF ¨

/

CTO ¨

/

Probation ¨

Is there any risk issues (including criminal convictions) involved in visiting the client?

/

YES / NO / NOT KNOWN

If YES, please specify

Are there any pets/ animals living with the client?

/

YES / NO / NOT KNOWN

If YES, please specify

For agencies making the referral PLEASE ENCLOSE A FACE RISK ASSESSMENT (or other appropriate risk assessment)
Equal Opportunities
Positive Pathways strongly believes that particular groups of potential and actual service users are at risk of finding services inaccessible, or of experiencing on-going poor mental health and poor quality of life, such as people from Black or Minority Ethnic communities, Women, Gay men, Lesbians and Disabled people.
Because of this, we need to make sure that we are an accessible service and to do this we must monitor the referrals that we receive to make sure that we are reaching all sections of society.
This page is designed to be detached from the rest of the form upon receipt. The information is anonymised ; it will be stored separately from client files and used for monitoring and statistical reasons only.
How do you identify yourself (gender): (Please circle)

Male

/

Female

Do you live and work in the gender assigned at birth? (Please circle)

Yes

/

No

/

Did not want to state

How do you identify yourself (sexuality): (Please circle)

Lesbian / Gay / Heterosexual / Straight
Bisexual / Did not want to state / Other

What is your cultural background: (Please circle)

Did not want to state

White / Dual / Asian or British Asian / Black or Black British / Other Ethnic Group
British / White and Asian / Indian / Caribbean / Chinese
Irish / White and Black African / Pakistani / African / Gypsy/Traveller
Other / White and Black Caribbean / Bangladeshi / Other / Other
Other / Kashmiri
Other

Do you have a physical health problem that affects your life on a day to day basis, or consider yourself physically disabled? (Please circle)

Yes / No / Did not want to state
Do you have a religion: (Please circle)
Christian / Buddhist / None
Hindu / Muslim / Other
Sikh / Jewish / Did not want to state
What is your relationship status: (Please circle)
Married / Co-habiting / Other
Civil Partnership / Single / Did not want to state
What is your residency status: (Please circle)
British Citizen / EU National / Refugee / Other
Asylum Seeker / Foreign Student / Destitute / Did not want to state

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