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Exceed Housing Association Limited – Referral Form
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Referral Form
REFERRAL FORM FOR SUPPORTED ACCOMMODATION
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Step 8
SECTION 1 – REFERRAL AGENCY DETAILS
Referral Agency
Phone
Email
Reason for Referral
SECTION 2 - APPLICANTS DETAILS
Name
Address
Date of Birth
Gender
Contact Number
NINO
Benefit Status
Immigration Status
Entry Date to UK
Ethnicity
Next of Kin / Relationship
Next of Kin Address
Next of Kin Contact Number
SECTION 3. PREVIOUS ADDRESS HISTORY (INCLUDING SUPPORTED ACCOMMODATION)
Address
Dates / Duration
Occupany Type
Reason for Leaving
Address
Dates / Duration
Occupany Type
Reason for Leaving
Address
Dates / Duration
Occupany Type
Reason for Leaving
SECTION 4 – APPLICANT MEDICAL BACKGROUND / HISTORY
Social Worker / CPN / Probation Officer/ Other
GP Name / Address - if applicable
Has Client ever been detailed / sectioned under the Mental Health Act? / Details
Physical Health History
Present medication and / or Treatment
Criminal Convictions / Community Order incl DATES
Other Relevant Information
SECTION 5 – SUPPORT GROUP / SUPPORT NEEDS - Please provide details of level and type of support required
Mental Health issues
YES
NO
Support Needs
Single Homeless with Support Needs
YES
NO
Support Needs
Training Education Employment
YES
NO
Support Needs
Leisure Cultural Faith Informal Learning Activities
YES
NO
Support Needs
Primary Health Care Mental Health or Drug / Alcohol Services
YES
NO
Support Needs
Accommodation / Housing
YES
NO
Support Needs
Safeguarding: Avoiding self-harm and/or causing harm to others/avoiding harm by others
YES
NO
Support Needs
Independent Living Skills
YES
NO
Support Needs
Inclusion in community
YES
NO
Support Needs
Social Isolation / Contact with family / friends
YES
NO
Support Needs
Other (Please specify)
YES
NO
Support Needs
SECTION 6 – RISK ASSESSMENT - *RISK ASSESSMENT (WE WILL NOT ACCEPT REFERRALS WITHOUT A CURRENT RISK ASSEESSMENT) PLEASE PROVIDE INFORMATION BELOW (OR SEND CURRENT RISK ASSESSMENT)
DOES APPLICANT HAVE A HISTORY OF BEHAVIOURAL ISSUES - IF SO PLEASE INDICATE RISK LEVEL ASLOW/MEDIUM/HIGH AND POTENTIAL TRIGGERS / POTENTIAL VICTIMS
VIOLENCE, AGGRESSIVE BEHAVIOUR
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
SELF-HARM / SUICIDE / MENTAL HEALTH FORMAL DIAGNOSIS
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
DRUG / ALCOHOL MISUSE
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
CHILD PROETECTION ISSUES
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
SEXUAL OR SCHEDULE 1 OFFENCE
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
CRIMINAL CONVICTIONS / OFFENCES
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
SELF-NEGLECT / NEGLECT OF OTHERS
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
ANTISOCIAL BEHAVIOUR
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
DAMAGE TO PROPERTY
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
ARSON
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
ANY OTHER INFORMATION
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
IS THE APPLICANT AT RISK OF HARM FROM OTHERS? IF YES PLEASE STATE BY WHOM AND PROVIDE DETAILS
LOW
MEDIUM
HIGH
Triggers / Potential Victims etc.
SECTION 7 – AUTHORISATION - APPLICANT / REFERRAL AGENCY
I give my consent to the disclosure of this information for the purpose of finding accommodation and to the disclosure of any supplementary information attached for housing purposes I give my permission for the outcome of this referral to be explained to the referral agency I agree to participate in a support package including support planning and assessment
I would / would not like a copy of this referral (Delete as appropriate)
YES
NO
SECTION 8 - SUPPORTING DOCUMENTATION / ADDITIONAL INFORMATION
Additional Information
FILE ATTACMENTS
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PLEASE NOTE: CAPITA HOUSING IS AN EQUAL OPPORTUNITIES HOUSING PROVIDER. HOWEVER, WE RESERVE THE RIGHT TO REFUSE REFERRALS WITH A HISTORY OF ARSON (INSURANCE REGULATIONS) AND SEX OFFENCES AGAINST CHILDREN.
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