AGENCY REQUEST FOR housing related FLOATINGSUPPORT FOR PRIVATE and housing association TENANTS.
oNCE THE sar RECEIVES THE completed FORM THE INFORMATION WILL BE ASSESSED AGAINST THE FLOATING SUPPORT CRITERIA. iF THE APPLICANT IS ELIGIBLE for floating support THEY WILL BE REFERRED to floating support providers OR PLACED ON A WAITING LIST. IF THE APPLICANT IS NOT ELIGIBLE THE AGENCY who made the request will be NOTIFIED of the ouicome.Please see guidance notes for information on completing the form.
Please email the fully completed form to OR
NON –LCC AGENCIES, please can you PASSWORD PROTECT ANY REFERRALS you send to the SAR.
Request FROM: (InClude name of agency, contact details including email and telephone number/s)Applicant / household Information
Surname: / Forename(s): / Joint application: / Y / N
Date of birth: / Age: / NI No: / Gender identity:
Is your gender identity the same as the gender you were originally assigned at birth? / Y / N / Prefer not to say
Ethnicity: / Interpreter required: / Y / N / Language: / Immigration status:
Sexual orientation: / Religion & Belief:
Contact number: / Contact details:
Current Address:
Other household members (name) / Date of birth / Age / Gender / Relationship to applicant
Is anyone within the household pregnant? / Details: / Due date:
Does any of the household have pets?
housing information
Brief description of applicant’s presenting problems, difficulties or concerns:
Housing Application No: / HA Status:
Current Housing: / Last ‘accommodation’ if different to current / Cause of homelessness
Private Tenancy / Rough sleeping / Relationship violence – partner
Living with friends / relatives / Sofa surfing / Relationship violence – other
Living with partner / Temp accommodation (non-funded) / Arrears eviction
Owner occupier / Refuge (funded) / ATL – Relationship breakdown
Housing Association Tenancy / Refuge (non-funded) / ATL – Overcrowded
Council Tenancy / Hospital / ASB Eviction
NASS / Prison* / Abandoned
HM Forces / Probation approved premises* / Relationship breakdown
Foster care / care home etc+ / BASS* / Racial violence
Tied accommodation / Other violence
Residential care home / Racial harassment
Other harassment
Accommodation ended
Leaving custody / approved premises
Brief address history (5 years) – does this include any periods in hospital, prison etc?
Address / Time there / Address Type / Reason for leaving / Joint owner / tenant
Total number of admissions to temporary accommodation over last 2 years?
initial needs assessment(if joint application consider both individuals)
Agencies involved:
Agency (e.g. CPN / Midwife / Social Worker) / Contact Name / Location
GP: / Dentist:
Do you consider yourself to be disabled? / Y / N
If YES what is the nature of the disability (tick all that apply): / Mobility / Wheelchair user
Visual impairment / Hearing impairment / Progressive disability / chronic illness (e.g. MS, Cancer)
Mental health / Learning disability / Autistic Spectrum Disorder
Other (please specify):
Relevant Medical History:
Recent medical / hospital admission? Y / N / Has there been a mental health diagnosis? Y / N
Employed: Y / N / In training / education: Y / N
Brief details of benefits / employment / training / education:
Vulnerabilities / support needs (indicate the primary need with a 1 and secondary needs with a 2 (upto a maximum of 3):
Older people with support needs / Older people with dementia and mental health problems / Frail elderly
Mental health problems / Learning disabilities / Physical or sensory disability
Single homeless with support needs / Alcohol misuse problems / Drug misuse problems
Offenders or at risk of offending* / Mentally disordered offenders* / Young people at risk+
Young people leaving care+ / People at risk of domestic violence / People with HIV/AIDS
Homeless families with support needs / Refugees / Teenage parents
Rough sleeper / Gypsies & Travellers with support needs / Generic / Complex needs
Is housing-related support required in relation to: Please attach any relevant supporting information
Managing income/ accessing employment / Y / N / Participating in education / training / leisure activities / contacting family / Y / N / Being healthy / Y/ N
Staying safe, finding / maintaining accom. / Y / N / Developing confidence / Y / N
Comments / Details:
initial RISK ASSESSMENT(if joint application consider both individuals)
– Indicate all risks identified through the assessment process
Risk to others / Risk to self
History of violence / aggressive behaviour / Suicide attempts
Risk to children / Self-harm
Arson / fire setting / Drug use
Anti-social behaviour / Alcohol use
Sexual offences / Self-neglect
Previous offending history / Risk of abuse from others
Suicidal thoughts
Other risks / Comments and details:
Have you ever been refused support and or evicted from housing support services? Y / N If yes please provide details:
oNCE THE sar RECEIVES THE completed FORM THE INFORMATION WILL BE ASSESSED AGAINST THE FLOATING SUPPORT CRITERIA. iF THE APPLICANT IS ELIGIBLE for floating support THEY WILL BE REFERRED to floating support providers OR PLACED ON A WAITING LIST. IF THE APPLICANT IS NOT ELIGIBLE THE AGENCY who made the request will be NOTIFIED of the ouicome.
Please see guidance notes for information on completing the form.
Please email the fully completed form to
NON –LCC AGENCIES, please can you PASSWORD PROTECT ANY REFERRALS you send to the SAR.
*additional offender
Offender Manager / Case Worker: / OM Team / CRC:
Risk of harm assessed by probation services / YOS / Choose an item. / MAPPA Level / Choose an item. / MAPPA Category / Choose an item. /
Probation / YOS status / Choose an item. / Date of release / commencement / SED / Order end
Current offences & dates:
+additional children and young people details
Social work team involved: / Choose an item. /
Is there a care / family support plan? / Y / N / Is there a Children’s Protection Plan? / Y / N
Under what duty is support being provided?
Will Children’s Services be responsible for paying rent? / Y / N
National Probation Service & Community Rehabilitation Company (Leicestershire) Recommendations
support PreferenceService / Reason/s preferred option / priority of case / date required
Norman House
Bradgate House
Beacon Hill
Floating support for offenders / ex-offenders
Floating support (non-specialised)
Children’s Services Recommendations
support recommendationService / Reason/s preferred option / priority of case / date required
Teenage parent accommodation (16-21)
Accommodation for young people (16-25)
Accommodation for families
Accommodation for singles
Floating support
Declaration / authorisation
The information on the assessment form will be made available to providers / organisations that are able to assist you / your household obtain the correct level of support and enable you to achieve and sustain independent accommodation.
By signing this form:
- I give my permission for this information to be used by Leicester City Council and our partners to deliver and improve services and fulfil our statutory duties
- I give my permission for this referral and support plans and monitoring information to be shared with the referred housing support provider and Leicester City Council’s Housing Options Service
- I give my permission for Leicester City Council to obtain further information from other relevant agencies which may include, for example, Adult Social Care, Children’s Services, housing providers, police, probation, benefit agencies and share this with housing support providers.
- If a support placement is available I agree to take part in a support package; including the assessment process, support planning and engaging with the support provided
- I confirm that the information contained in this document is true and includes all relevant information required to correctly assess my referral / support needs.
We will treat your information as confidential and will only share it with other organisations (as detailed above) and when required by law to share it or unless you or any other person will come to some harm if we do not share it. For more information see the privacy statement on
Name/s of applicant
Signature of applicant / Date
Signature of joint applicant, if applicable / Date
Information from SAR Assessment – SAR to complete
eligibility criteria for temporary accommodationa) Family, pregnant woman / g) Young offenders and ex-offenders
b) Vulnerable adult / h) Council tenants in an emergency
c) Children leaving care / i) People over 60
d) High risk offenders / j) People rough sleeping / risk of rough sleeping
e) Offenders / ex-offenders leaving approved premises / k) Other offenders / ex-offenders
f) Vulnerable adults and families / l) People in / waiting for drug and alcohol programmes
m) Not eligible
TYPE OF DUTY
Full / Interim
PRIORITISATION criteria for FLOATING SUPPORT
GROUP A / GROUP B
GROUP C / GROUP D
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