ALABARÉ CHRISTIAN CARE & SUPPORT

Confidential Information

ALABARÉ VETERANS PROJECTS

APPLICATION/REFERRAL FORM
Version 2, 2012

Data Protection Act

We are subject to the Access of Record Act 1987 and the Data Protection Act 1984 regarding computerised record keeping. We are required to disclose information held about a client should they request it unless limited exemption apply including: Disclosure may carry a serious risk of harm to the individual or others. Release of information could prejudice the prevention or detection of a crime

Health & Safety

Failure to disclose important information which may result in staff and/or other service users being put at risk, may contravene the Safety at Work expectations in Health & Safety legislation

Alabaré Christian Care & Support

Our vision: A society where everyone has the opportunity to enjoy a fulfilling life.

Our mission: We enable people to enjoy a fulfilling life by working with individuals, communities and other organizations to:

·  Generate sustainable solutions within our communities

·  Provide high quality accommodation and support services

·  Equip people with skills for living and working

·  Overcome the barriers people face

Our values: The values that lie at the heart of our work are:

·  Care for service users, who are often vulnerable and marginalized

·  Compassion for those is difficulty or distress

·  Generosity in allowing people another chance

·  Respect for all, valuing each person, their experience, opinions and choices

Who we work with: we help some of the most vulnerable people in our communities, enabling them to overcome the barriers they face and achieve fulfilling lives. Through more than 40 projects in the South and South West, we provide support, accommodation and training for:

§  People who are homeless or at risk of becoming homeless

§  People with mental ill-health

§  Ex-Armed Forces personnel

§  People with learning disabilities

§  Prisoners and ex-offenders

§  Young People

§  Women leaving the sex-industry

Alabaré Christian Care & Support Policy on Applications:

Alabare operates an equal opportunities policy. No applicant will be treated less favourably because of sexuality, colour, race, religion, ethnic origin or HIV status.

From time to time, the Trust reserves the right to apply a Positive Action Strategy to address under-representation of a certain group or groups.

Referral Process: This application form is the first step in a multi-step process outlined overleaf. Alabaré has tried as far as possible to simplify the various forms but it is essential that a full assessment is carried out on the suitability of each candidate.

Application Form for Supported Housing

Please note - we provide services for people who need support. We will use this application to help us decide if we can meet your individual needs. If you meet our criteria, we will invite you to an interview to discuss your support needs. Information given will be treated as strictly confidential. If you need help to complete the form then please contact us for advice. Incomplete forms may be returned for more detail.

Referring Agency/Organisation Details (If not self-referring)

Name of Referrer
Job Title
Organisation
Telephone number
Signature
Date
Referring agency only
Was this form completed with your client? Yes/No
Has agency Risk Assessment been attached? Yes/No
If able please attach copies of most recent professional reports, e.g. psychiatric report/probation report/current care plan etc. This is essential to enable us to build a realistic interview plan.
I am interested in applying to (please tick at least one option:
□ Alabaré Hampshire Home for Veterans
□ Alabaré Plymouth Home for Veterans (Mon Abri)
□ Alabaré Weymouth Home for Veterans
□ Alabaré Bristol Home for Veterans
□ Alabaré Salisbury Home for Veterans

Personal Information of the Applicant

Please note: the information given in answer to the questions below will be forwarded to The Royal British Legion to verify your service in the British Armed Forces. Please read them carefully and answer fully to avoid a delay in this information being processed. You may not be offered accommodation until your service has been fully verified.

Applicants Full Name (including middle name):
Contact Address:
Post Code: / Telephone No:
Date of Birth: / Age:
National Insurance Number:
Which section of the Armed Forces did you serve in: (IE Army, Navy, RAF etc), and which regiment/sqn etc? What were start and end dates of service?
What is your Service Identification Number:
Have you previously applied or resided in any Alabare properties? If yes, please provide dates of residence and name of project.
Please tell us the main reason you feel you became homeless and/or require support:

Income

Source of Income / Amount / Frequency
Do you have any savings (if so how much)?
Do you have any debts or fines? Please specify.

Mental and Physical Health

1. Do you have any history of mental or physical health problems or disabilities?
2. How long have you had these conditions?
3. What treatment are you receiving? Please provide details of any medication, and any other therapies being recieved.
4. How does this affect your day to day living?

Substance Misuse

1. Have you ever abused any of the following substances? (Please tick)
o  Alcohol
o  Prescribed drugs
o  Illicit drugs
o  Solvents
o  Others (please specify)
2. Please give details, including frequency and consumption level;
3. When and why do you think you started?
4. Do you see yourself as being addicted?
5. Have you attempted to resolve these problems before? If so, when? Why do you think this was unsuccessful?
6. Did you have any support from family, friends or agencies? If so, please tell us who;
7. Are you prepared to attend a relapse prevention course/detox?
8. What are you hoping to achieve in relation to your addiction issues?

Independent Living Skills

Do you need help with any of the following? (please tick)
o  Reading
o  Writing
o  Filling in forms
o  Managing money (budgeting)
o  Maths
o  Shopping / Planning menu’s
o  Cooking
o  Emergency procedures (calling Fire, Police, Ambulance etc.)
o  Personal hygiene
o  Personal laundry
o  Socialization
o  Personal security
o  Other (please specify)

Offending history

Please give details of any offences committed and spent convictions. Please include any pending court appearances/upcoming legal proceedings;

Shared Living

Please tell us how you have coped or how you would cope and what support you may require, including any previous experiences.

Other Support Needs

Please include in this section:
o  Further Education
o  Hobbies
o  Careers Advice
o  Job Training
o  Coping with Feelings
o  Cultural
o  Religious
Tell us specifically what ambitions you have in these areas, if any;

Additional Information

Please use this space to give us any other information which you think may be useful to us to assess your application. (Please continue on a separate sheet if necessary).

Please give details of someone we can contact for further information about your application (CPN, Social Worker, Probation Officer, MOD worker or other professional who is familiar with your support needs).

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Name:
Organisation:
Telephone Number:
Address:

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Name:
Organisation:
Telephone Number:
Address:

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Name:
Organisation:
Telephone Number:
Address:

Who recommended you to Alabaré Christian Care & Support?

The Royal British Legion
SSAFA Forces Help
Other Forces charities
Local Housing Authority
Police
Prison/Probation service
Social Services
Voluntary Agency
Health Service/GP
Community Mental Health Team
Housing Association/RSL
Other (please specify)

Consent Form and Statement

As far as I know, the answers I have written on this form are true. I understand that Alabaré Christian Care and Support reserves the right to terminate my licence to occupy any accommodation and withdraw support which has been obtained by deliberately providing false information or withholding essential information.

I hereby give permission for relevant information to be given to Alabaré Christian Care and Support in respect of my application, including from the persons/organisations specified on page 9 of this form, and for information to be shared with the funders of the projects I have applied to.

Applicant’s signature ……………………………………………Date …………………

Referrer’s signature………………………………………………Date …..…………...

Job Title …………………………………………………………………………………

Are you related to any member of Alabaré Christian Care & Support staff or any committee member (paid or unpaid)? If yes please specify relationship.
Yes No
Relationship;

1