Tenancy Support Family Services Referral Form

Family Mosaic Mental Health Services

Floating Support

Does the client require support due to their mental health Y/N

If the answer is NO please do not refer to service.

Is their any secondary issue? (Tick all that apply)

Vulnerable elderly (age 55 years +) Unable to manage in home

 Fleeing domestic violence

 Person with learning difficulties  Person with HIV/AIDS

Person with a physical or sensory disability  Refugees/asylum seekers

Person with alcohol problems  Person with drug problems

 Offender or person at risk of offending Other (please state)

What support needs does the client have?(Tick all that apply)

 Alcohol (mis) use (current)  Language/literacy

 Alcohol (mis) use (previous) Mild mental health problems

 Basic life skills Mild learning difficulties

Befriending/loneliness/isolation  Never lived independently

 Budgeting debt/money advice  Offending history

Personality/behavioural disorder  Drug (mis) use (current)

 Relationship breakdown  Drug (mis) use (previous)

 Sexuality issues  Move-on into sheltered housing History of neighbour nuisance  Victim of violence/harassment

 Homeless/transient accommodation history Assistance with tenancy

ASB

 Other ______ Mobility/Physical Disability

If you have not ticked any but are sure that this person should be referred to the Mental Health Floating Support Service, contact the team on 0300 123 1339 for advice or email us on or

Section 2General Details

Please give as much information as you can about the tenant you are referring.

Date of referral ______

Full name of client ______

Address ______

______

Post Code ______

Telephone No.______

Diagnosis ______

Type of tenancySecure  Assured

Landlord and Tenancy start date:

Date of Birth______

Ethnicity______

First Language______

Interpreter required? Yes  No 

Has the client agreed to the referral Yes  No 

If not, please state reason ______

Last contact with client______

Housing Officer (Name) ______Telephone______

Section 3Support Issues

What are your immediate concerns and reason for this referral?

______

______

______

If you want to add more details about the tenant's additional support needs (e.g. physical/sensory disability, mental health needs etc?) use this section

______

______

______

What other support does the tenant receive (e.g. do they have a social worker, community psychiatric nurse, GP; family/friends/carers?)? Please give contact details.

______

Would you like any family or friends involved in your assessment and support if accepted into our service?

Yes  No 

If yes please state full details:

Section 4Risk

Is the customer currently on any MOJ restrictions or a CTO?

Yes  No 

If yes please provide details of any restrictions:

Is the tenant at risk of losing their home? If so, why?

______

______

______

Is the Landlord taking legal action against them?

______

______

______

Is the tenant a risk to themselves or others? (i.e. Do they have a history of falls, challenging behaviour or self-harm? )

______

Are there any health and safety risks at the property which may prevent us from entering the property? (please tick)

Fleas/other infestationsCockroaches

Rats/MiceHoarding

SharpsUnsanitary conditions

Unsafe property (eg structural problems)

Other/Additional information

______

______

Section 5Referral Details

Name of person making the referral: ______

Job title: ______

Organisation: ______

Address: ______

Telephone ______Fax ______E-mail______

Signature ______Date ______

Please send risk assessment, CPA and any other relevant documentation with referral.

Can referrer attend assessment?

Yes  No 

Section 6 To be completed by the Family Mosaic

Date received: ……………………….

Date Assessed………………………..

Referral Accepted Yes  No 

If not, please state why………………………………………………………….

PRIORITY

Please return to: Mental Health Services, Family Mosaic 38 Marsh Hill, London E9 5PE

Tel 0300 123 1339 or e mail: