SINGLE ASSESSMENT FORM
The following fields are mandatory. Please complete in ALL details
Please complete in CAPITALS letters and in black ink
Client Details
Title
Full Name
Date Of Birth
Gender / Male: / Female:
Current Address
Town / Postcode:
Contact Number
Ethnicity / Religion:
Pregnant / Yes / No
If YES - Expected date of delivery:
Referral Details
Date of Referral
Reason for Referral:
Floating Support[ ]
Accommodation based Service[ ]
Accommodation & Floating Support Service[ ]
Details of Referrer
Type of organisation you work for(ie Prison, Probation, Hospital)
Name of service you work for
Title/Position/Job role
Full Address including Postcode
Referral Description / Comments & Recommendations
Family Members
Please detail all members of the household that will be included in the application
Name:
Relationship to you:
Date Of Birth (D/M/Y):
Age:
Pregnant: Yes / No / Name:
Relationship to you:
Date Of Birth (D/M/Y):
Age:
Pregnant: Yes / No
Name:
Relationship to you:
Date Of Birth (D/M/Y):
Age:
Pregnant: Yes / No / Name:
Relationship to you:
Date Of Birth (D/M/Y):
Age:
Pregnant: Yes / No
Name:
Relationship to you:
Date Of Birth (D/M/Y):
Age:
Pregnant: Yes / No / Name:
Relationship to you:
Date Of Birth (D/M/Y):
Age:
Pregnant: Yes / No
Address History Details
Please give the address details for the last 5 years, including area and length of time spent there
Date From / Date To / Address / Area
Local Connection Details
Please state local Connection to the area
Domestic Violence / Resident – 6 – 12 months
Employment / Resident – 3 out of 5 Years
Family Association / Resident – 12 out of 18 Years
No Local Connection to Torbay / Special
No local connection anywhere / Other
Income Details
Please state Household income details
Family Member / Benefit / income type / Weekly Amount
Preferred Accommodation Details
If the client has requested Supported Accommodation please complete the section below
Please specify the town (s) you would prefer to live in
Brixham / Paignton
Torquay / Any / Other
Are there preferred areas within the town (s)Yes [ ] No [ ]
Please state:
Please Specify number of bedrooms required?
Please specify any property requirements?
Overall details, Are there any services, areas, types of accommodation that would not be appropriate?
Current Accommodation Details
Please state Current Accommodation Details
Does the client currently haveaccommodation? Yes [ ] No [ ]
If Yes what type of accommodation do you currently live in?
B & B / Hotel / Temp Accom / Residential Care Home
Hospital / Rough Sleeping
Housing Association
(Riviera, Westcountry, etc.) / Social Services Placement
Living with Family / Friends / Supporting People Service
Own your own Home / Tied Housing / Rented with Job
Private Sector Tenancy / Women’s Refuge
Prison / Other: Please specify
If NO current accommodation, please specify reason for loss of previous accommodation?
Is the client at risk of losing their current home / accommodation?Yes [ ] No [ ]
If YES please state why this is (eg have been issued a Notice To Quit):
Does the client have any current rent arrears? Yes [ ] No [ ]
Has the client previously been in rent arrears? Yes [ ] No [ ]
If YES have they resulted in an eviction:
Is the housing related support need immediate or for a specific date? Yes [ ] No [ ]
(eg when discharged from hospital/prison)
If YES please state date and details:
Has the client previously been in a Supporting People accommodation or Floating Support Service? Yes [ ] No [ ]
If YES please state project (s) and details:
Financial Information
Economic status (please select option applicable to client)
Full Time Work / Not Seeking Work
Govt Training / New Deal / Part Time Work
Job Seeker / Retired
Long Term Sick / Disabled / Student
Other: Please specify
Does the client have any savings?Yes [ ] No [ ]
If YES how much £
Other Agencies / Professionals working with the client
Please complete this section in full, including the question about the ‘expected length’ and any conditions of ongoing involvement of any agency currently working with the client. Please include statutory and other specialist agencies, eg GP, Psychiatrist, CPN, Social worker etc.
1. Agency:
Officer:
Email Address:
Telephone No:
2. Agency:
Officer:
Email Address:
Telephone No:
Client Category
Please identify a primary and secondary support need that currently applies to the client (from the list below).
Main Support Need: 1
Secondary Support Need: 2
SUPPORT NEEDS ( Please tick any other support needs that also apply)
Acquired Brain Injury / Older Frail Person
Asylum Seeker / Older person with support need
Fleeing Domestic Violence / Physical Disability
Hearing Impairment / Refugee
History of alcohol dependency/use / Rough Sleeper
History of drug dependency/use / Sensory Disability
HIV/AIDS / Single Homeless
Homeless Family / Teenage Parent ( 16 – 19 )
Learning Disability / Traveller
Long Term Condition / Visual Impairment
Mental Health / Young Person (Care Leaver)
Mentally disordered offender / Young person at risk under 18
Subject to a Community Order / Young person at risk (18 – 24)
Recently released from custody / Complex Needs
Overview of support needs
Please provide an overview of the support required, please detail current household situation and what is hoped to be achieved from the Housing Related Support Service whether Accommodation based or Floating Support
General Support Needs
Please select the current General Support Needs
Adult Protection Issues / Isolated from family
Child protection Issues / Parenting Support Needed
Current / Immediate Homeless / Pregnant / Lone Parent
Current / Past Debt Issues / Risk Of Isolation
Current / Past Anti – Social behaviour / Victim Of Harassment
Excluded from school / Young Person subject to YOT
Other - Please Specify:
Personal Support Needs
Please select the clients current Personal Support Needs
Developing personal relationships / Paranoid / Delusional Thoughts
Domestic Abuse / Personality Disorder
Emotional / Behavioural Issues / Poor Anger Management
Impulsive Behaviour / Poor numeracy & Literacy skills
Lacks Inhibition / Self Neglect
Panic / Anxiety Attacks / Social Phobias
Paranoia / Suicidal Ideation
Other – Please Specify:
Housing Related Support Needs
The following is a list of Support Needs that the client may require. Please select any applicable
Accessing community activities / developing social networks / Reminder to keep appointments
Accessing education, training or employment / Reminder to take medication
Advice around home maintenance / Setting up a new home or tenancy
Debt Management / Support with Life Skills
Maximising Income or Budgeting / Support with shopping
Meal Preparation and planning / Understanding and Filling in forms
Prompting re personal care
Other: Please specify:
Medical Support Needs
Please select the clients Current Medical Support Needs
Acquired Brain Injury (ABI) / Long Term Condition
Alzheimer’s / Mobility Difficulties
Cognition / Memory Loss / Multiple Sclerosis
Dementia / Out PatientHospital Treatment
Hearing Impairment / Problems with taking medication
Hepatitis / Stroke
HIV / AIDS / Visual Impairment
Learning Disability / Other - Please Specify:
Is the client currently receiving any prescribed medication? Yes [ ] No [ ]
If YES please state details:
Mental Health Needs
Has a Mental Health condition been diagnosed?Yes [ ] No [ ]
If YES please state the condition:
Have the client ever been admitted into a Psychiatric Unit?Yes [ ] No [ ]
If YES please state approximate date and details
Is the client currently receiving any of the following support medication (please tick)
On Depot / CPA Standard / CPA Enhanced / Supported by the MH Team
Please give details:
Domestic Abuse Needs
Domestic abuse refers to physical, sexual, economic abuse, or neglect of an individual by a partner, ex partner, carer of family members in an existing or previous relationship.
Would you consider yourself a victim of domestic abuse?Yes [ ] No [ ]
If YES please state details:
Access and Communication Needs
Is the client able to climb stairs?Yes [ ] No [ ]
Does the client require wheelchair accessible accommodation?Yes [ ] No [ ]
Does the client have any adaptations / equipment needs?Yes [ ] No [ ]
If YES please state, e.g. Wet Room, Telecare, Flashing smoke alarms
Is an interpreter, signer or other specialist communication person needed for interviews? Yes [ ] No [ ]
Please give details:
Is the client able to read and write English?Yes [ ] No [ ]
Does the client need support to understand or retain information?Yes [ ] No [ ]
If YES please state, e.g. Short term memory loss, Cognition difficulties.
Offences/Convictions
Please state any convictions in the following:
Violence / Details:
Sexual / Details:
Arson / Details:
Is the client currently subject to a community sentence?Yes [ ] No [ ]
If YES please give details:
Do any of the following conditions apply to the Community Sentence (please tick)
Curfew / Tagging / Residency / Exclusion
Please give details:
Is the client currently subject to a Licence/Supervision Order? Yes [ ] No [ ]
If YES please give details including date ends and conditions:
Please give details of clients current Probation Officer, Including Name & Telephone Number:
Substance Misuse
Does the client currently have, or within the past 5 years, misused any of the following? Yes [ ] No [ ]
Substance / Current / Previous / Details
Amphetamines
Alcohol
Cocaine
Crack Cocaine
Heroin
Methadone
Has a rehab / detox programme been completed in the last 5 years? Yes [ ] No [ ]
If YES please state approximate date and details
Learning Disability Needs
Has the client been assessed as having a diagnosed learning disability by the Community disability team? Yes [ ] No [ ]
Is the client eligible for Social care services/Meet Fair Access to Care?Yes [ ] No [ ]
Physical & Sensory Needs
Has the client any Physical or Sensory issues?Yes [ ] No [ ]
If YES please give details:
Risk Management
The risk assessment must becompleted in full in all cases.
This is to ensure an appropriate referral can be made. Under the management of Health and Safety Regulations and the 1974 ACT, employers have a duty of care towards other tenants, landlords and staff. Are there any significant Health and Safety issues that have not already been disclosed that we should be aware of and that might affect the application.
BY SIGNING THIS FORM YOU ARE DECLARING THAT ALL THE RELEVANT AND CURRENT INFORMATION HAS BEEN INCLUDED IN THE ABOVE STATEMENTS and, if in custody, all relevant and current documentation, ie EOasys ‘Risk of Harm’ assessment, is included in support of this application.
SPECIFIC CAUTIONS TO BE TAKEN WHEN INTERVIEWING
Type of Caution / YES/NO / Caution Details
NO CAUTIONS / Details:
NO LONE VISTIS / Details:
NO LONE INTERVIEWS / Details:
NO FEMALES TO INTERVIEW / Details:
NO MALES TO INTERVIEW / Details:
NO WOMEN TO VISIT ALONE / Details:
NO HOME VISITS / Details:
Risk Details
Please state any Risk Details you feel that may be relevant:
Risk Assessment
For every box ticked in relation to risk please provide clear details of nature of risk
and all relevant offending: Please include date of MAPPA if relevant:
MAPPA Category01 2 3 
Level12  3 
Risk of Self Harm
Level of Risk / Tick Level
None
Low
Medium
High
Very High
Details of risk:
What measures are currently in place to manage this risk?
Agencies Involved:
Name of Key Worker(S)Phone Number:
Risk to Staff / Providers
Level of Risk / Tick Level
None
Low
Medium
High
Very High
Details of risk:
What measures are currently in place to manage this risk?
Agencies Involved:
Name of Key Worker(S) Phone Number:
Risk to Other Residents
Level of Risk / Tick Level
None
Low
Medium
High
Very High
Details of risk
What measures are currently in place to manage this risk?
Agencies Involved:
Name of Key Worker(S) Phone Number:
Risk to Public
Level of Risk / Tick Level
None
Low
Medium
High
Very High
Details of risk
What measures are currently in place to manage this risk?
Agencies Involved:
Name of Key Worker(S) Phone Number:
Risk From Family
Level of Risk / Tick Level
None
Low
Medium
High
Very High
Details of risk:
What measures are currently in place to manage this risk?
Agencies Involved:
Name of Key Worker(S) Phone Number:
Risk From Partner / Other
Level of Risk / Tick Level
None
Low
Medium
High
Very High
Details of risk:
What measures are currently in place to manage this risk?
Agencies Involved:
Name of Key Worker(S) Phone Number:
Risk toChildren
Level of Risk / Tick Level
None
Low
Medium
High
Very High
Details of risk:
What measures are currently in place to manage this risk?
Agencies Involved:
Name of Key Worker(S) Phone Number:
Risk of Arson
Level of Risk / Tick Level
None
Low
Medium
High
Very High
Details of risk:
What measures are currently in place to manage this risk?
Agencies Involved:
Name of Key Worker(S) Phone Number:
Declaration and Client consent
General Service Provision:
To fulfil its obligations under the UK Data Protection Act, 1998 Torbay Council needs to let you know why we are asking for your information on this form, how we will use it, and also to ask for your consent to use your information in certain ways, where this is necessary. In some cases, you have a right to not to give us your consent if you do not want your information to be shared. However, it may be difficult to assist you with some of the services you need if you do not give your consent. It is also not always necessary to ask for your consent to use or share your information (see below), for example where we are allowed by law to do so.
Housing Services collect your information on this form in order to assist you in providing the services you have requested and ensuring that you receive the best service that meets your needs.,
We will share relevant information within Torbay Council, Housing Services and externally with other organisations and agencies, such as our service providers so that we can provide you with the most appropriate service,
We may also need to contact other organisations and agencies about the information you have provided to seek further information and/or clarification.
In exceptional circumstances, we will always disclose information to 3rd parties/bodies without your consent, for example where you pose a serious risk to yourself or others. We need to do this either because we are under a legal duty to do so, or to ensure your safety and/or the well being of others
In the case of Homelessness the following applies in addition to the general information above:
Under Section 214 of the Housing Act 1996 it is an offence for any applicant to make a false statement or knowingly withhold information relevant to his/her application.
It is also an offence for any applicant not to report any changes in his/her circumstances, which could influence their re-housing.
The information you provide on this form will also be used to investigate and process your homeless application and may be disclosed to other internal departments of the Council, their partner agencies or other Local Authorities for the purpose of verifying and processing your application.

Consent and Declaration:

I hereby agree to allow Torbay Council, Housing Services access to my personal files held by other agencies, including, but not limited to: Department for Work & Pension, Social Services, Medical Records, Police, Probation Service, Immigration Service, my/our employer/s, Utilities, Local Authorities (including Housing Benefit & Council Tax), Housing Associations, Landlords or Managing Agents /Loan Companies, in order to obtain information that maybe relevant to my case.

This declaration informs applicants that they will be liable to prosecution if any of the information is subsequently found to be false. We will prosecute and if you are found guilty, you could be ordered to pay a fine of up to £5,000 as set out in Section 214 of the Housing Act 1996, Part V11.

Signature: ______

Print Name: Date:

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