Referral for a Floating Support Service

REFERRAL FOR A FLOATING SUPPORT SERVICE

To process this application Bolton at Home will need to collect information of a personal and sensitive nature. Some of the information requested will be used for monitoring purposes and may be shared with others involved in providing your support. Please be honest whencompleting the form to help ensure we can assist you appropriately..

Section 1Which Support Service are you referring to?

(Please tick appropriate box)

The Preventative and Enabling Support Service /
The Family Intervention Floating Support Service /

Section 2Applicant Details

Surname: / First Name:
Date of Birth: / Age: / Male / Female
Former Names:
(if previously used) / Title: Mr Miss Ms Mrs
(Please circle)
Admin Step 1: Always search Gateway to avoid creating duplicate records.
Marital Status:
(Please Circle) / Single Cohabiting Engaged Married Separated Divorced
National Insurance No:
Home Phone: / Mobile:
Email:
Preferred Form of Contact / Home phone / Mobile / Letter
Email / Other:
Can we contact you at this address / on this number safely? Yes No
If no, please give reason why:

Section 3Referring Agency (if applicable)

Referrer’s Name: / Organisation
Address:
Phone: / Email

Section 4Support Needs

Please tick box(es)that best indicate your current situation

Support Needs / Tick / Support Needs / Tick / Support Needs / Tick
People with Mental Health issues / People with Learning Disabilities / People with Physical / Sensory Disabilities
People who have an Alcohol problems / People who have a Drug problems / Offenders or those at risk of Offending
Young People at risk / Young People leaving care / People at risk of Domestic Violence
People living with HIV or AIDS / Refugees (with permission to remain in the UK) / Traveller
Complex Needs / Older People with Support needs. / Other:

Section 5 Diversity and Ethnicity Information

Please tick box which best indicatesyour ethnicity.

Support Needs / Tick / Support Needs / Tick / Support Needs / Tick
White British / Black or Black British : African / Mixed – White / Black African
White Irish / Black or Black British : Caribbean / Mixed – White / Black Caribbean
White Other……………….. / Other Black ……………….. / Mixed - White / Asian
Chinese / Asian or Asian British : Indian / Mixed - Other ………….
Gypsy, Romany, or Irish Traveller / Asian or Asian British : Pakistani
Other …………………………. / Other Asian ….……………. / Not Known
Please advise us of your nationality.
What is your preferred / first language?
Do you need an interpreter? /
Yes /
No
Do you have any disabilities? /
Yes /
No /
Don’t know
If yes, please detail:
Visual / Hearing / Mobility / Progressive /
Chronic illness
Learning disability / Mental health / Other- please state

Section 6Housing Information

Present Address: / Post code:
C/o address
(if different): / Post code:

Description of Current Housing (please tick relevant box)

Owner Occupier / Private Rented Accommodation / Supported Housing Scheme
Bolton at Home / Other RSL and Housing Association / Refuge in Bolton
Parent’s Home (Lodger) / Other Relatives Home (Lodger) / Friends Home (Lodger)
Hostel in Bolton / Bed and Breakfast in Bolton / Other:

Addresses for the last 5 years (starting with current address first)

Address: / Date From / Date To / Type of tenure (private rented, lodger etc.) / Reason for leaving or moving.
X / X
Do you require support to maintain your existing tenancy? / Yes / No
Do you require support to access a new tenancy? / Yes / No

Section 7 –Other Household Members

Details of partner, children, and any other members of your household

(or expected delivery date)

Surname / Forename / Date of Birth
(or expected
delivery date) / Relationship
(e.g. partner, child etc.)

Section 8Rehousing(If required)

Have you registered on the HomesForBolton Housing Register? / Yes / No
Reference Number: (if known)

Section 9 Arrears and Debts

Current tenancy or mortgage arrears / Yes / No / Amount £
Former tenancy arrears / Yes / No / Amount £
Address of any former tenant arrears:

Do you have any other debts? (Please detail the most significant ones)

Debt: / Amount £
Debt: / Amount £
Debt: / Amount £
Debt: / Amount £

Section 10 Floating Support Requirements.

Please give any details of why you would like or needto receive a floating support service and how you feel this support will benefit you.

From the table below, please tick what types of support you feel you require:

Economic wellbeing / Enjoy and achieve / Be healthy / Stay safe / Make a positive contribution
Money management budget skills / Participating in learning training / Improving or maintaining good physical health / Maintaining safe and secure accommodation / Improving motivation and involvement
Accessing Work / Accessing social activities / Improving or maintaining goodmental health / Addressing issues leading
to Homelessness / Improving confidence

AccessingBenefits / Accessing religious & cultural activities. / Reducing or addressing drug use / Maximising Independent living skills / Achieving greater choice or control
Enhancing childcare parenting skills / Reducing or addressing alcohol use / Addressing issues of domestic abuse / Other-(please state)
Improving communication skills / Accessing aids & adaptations / Addressing issues of offending behaviour
Accessing relevant health care

Section 12 Risk Management Information

It is important that you read and understand the following statements.

In order for us to manage any risk, please can you tell us if you or a member of your family:

Yes / No / Don’t know
Have a history of or been convicted of violent or sexual offences? / / /
Have misused drugs, alcohol or other substances? / / /
Have been subject to a drug treatment order? / / /
Have been required to sign an Acceptable Behaviour Contract (ABC) or an Anti-Social Behaviour Order (ASBO)? / /
Have been treated or sectioned in hospital for mental health reasons? / / /
Have self harmed in the past (including overdose attempts)? / / /
Believe any of your or your family members behaviours are a risk to you or others? / / /
Are vulnerable to violence or abuse from others? / / /
Take any medication? / / /
Have been refused a floating support service in the past? / / /

If you ticked yes to any of the above, please provide details below including relevant dates:

If you are unable to provide further details about risks, this may delay the application process

Convictions

Please give details of any current offences that you, your partner,or any dependent children may have been charged with (pending appearance or conviction in Court) and details of all past criminal convictions.

OFFENCE/CONVICTIONSENTENCEDATES

………………………………………..…………………………….…………………………..

Please tick all the risk factors that are present in your current situation:

Self Harm or Neglect / / Mental Health Issues or Needs / / Abusive Relationships /
Vulnerable to Exploitation / / Physical Health / / Physical Safety /
Confusion / / Risk of Homelessness / / Family or Relationship Breakdown /
Loss, Bereavement or Grief / / Possible Breakdown of Support Arrangements / / Drug/Alcohol/Solvent Abuse and Use /
Child Protection Issues / / Offending History or Behaviour / / Violence / Aggression / Harm to Others /
Arson / Accidental Fires / / Anti-Social Behaviour / ASBO’s / / Financial Problems / Arrears / Debts /
Others (please state) / Others (please state) / Others (please state)

Please provide further details below of all risk issues identified:

(Please use Further Information Sheet if requiredand attach supporting letters or information)

…………………………………………………………………………………………………………………..

Section 14 Consent to Share Information

Do you consent to the information you provide being shared with others involved in your support? / Yes / No
Do you consent to us referring you to other relevant agencies? / Yes / No
Do you consent to us contacting other agencies in relation to your support needs? / Yes / No
Is there any specific information you do not want us to share, or are there any agencies you do not wish for your information to be shared with? Please detail:

Client Signatures

Signed (Client) ______Printed: ______Date: ______

Names of dependent children to whom this agreement also relates

1. ______2. ______

3. ______4. ______

Section 15 Any Further orAdditional Information

Please use this section to provide us with any further information about your current situation and support needs.

…………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………..

Please return this completed form to:

………………………………………………………………………………………………………………….

11. Joint Services Floating Support Referral Form - revised Sept 2012

Referral for a Floating Support Service

Section 8Rehousing(If required)

Section 9 Arrears and Debts

Do you have any other debts? (Please detail the most significant ones)

Section 11 Current Support Network

Section 12 Risk Management Information