Date:
Chapter 1 ‘The Limes’
Approved Tenancy Training Course ENTRY 3
· Are you 19 -25? Yes No (Delete as appropriate)
If you have answered Yes : Please ensure you answer the following questions below.
If you answered No : Please note this Tenancy Training course is only available to applicants aged 19+ , any person under 19 please contact the Limes to discuss other options available.
1)Aged 19 year’s plus .
2)Is willing and committed to complete the 8 week programme.
3)Is active in his/her own learning.
4)Is ready to live independently or with some support.
5)Is able to speak and understand English. (Please contact us for clarification, if required.)
6) Have you got an active housing application with Manchester City Council?.
If Yes, What is your housing application number? ………………….
7) Have you got a ‘Manchester connection’ (Please contact us for further clarification, if required.)
8) Is in housing need or wanting to learn the skills needed to maintain his/her current tenancy.
9) Has problems in existing Tenancy and has been put forward for Tenancy Training*
*Q9) Please ExplainReferral Agency Guidance Notes.
We aim to keep the named contact from the referring agency informed at all stages of the application process of our Tenancy Training programme. Referring agencies need to be involved and able to support young people to successfully access our service and be involved in the completion of our tenancy training programme.
Please inform the young person being referred about the tenancy training programme and explain the reasons for the referral. Please also secure consent from the young person at this stage. It is important that the young person is willing to engage with us if the tenancy training programme is to succeed.
We will contact all referrals received, confirming the status of their application.
Tenancy Training
Referral Form
Personal Details:
First Name: …………………………………………………………….
Surname: …………………………………………………………….
Address (if applicable): …………………………………………………………….
…………………………………………………………….
Postcode: …………………………………………………………….
Telephone Number: …………………………………………………………….
Date of Birth: …………………………………… AGE ……………….
National Insurance Number: ......
Male / Female: …………………………………………………………….
Homeless project (if applicable): …………………………………………………………….
Special Educational Needs or Physical Limitations (Mobility needs, Dyslexia, Difficulty with basic skills) Y/N if Yes please give more details:
ESOL Level (if applicable) Entry 1 Entry 2 Entry 3 Level 1 Level 2
Current Education Details ______
Current Housing Status:
Local Authority Tenancy Housing Association Tenancy Private Sector Tenancy
Supported Housing Direct Access Hostel Women’s Refuge
Foyer Approved Probation Hostel Bed and Breakfast
Living with Family Living with Friends Rough Sleeping
Other Temp Accommodation Children’s Home/Foster Care
Do you have a Live Housing Application with Manchester Move? Yes / No
If Yes, What band is your application currently sat in? …………………………
If No, Could you please explain why?
......
Risk Assessment. (MUST be completed in all cases) Please Circle: Yes or No
The risk assessment must be completed by a professional person, who has known the referrer for a minimum of 3 months. This person must also provide their contact details.
To your knowledge does the person have a current or past history in any of the following areas?
- Risk of Violence to Others Yes / No
(If Yes Please explain)
- Vulnerability to abuse and or violence from others Yes / No
(If Yes Please explain)
- History of offending (including arson, drugs offences, sexual offences & current offending behaviour) Yes / No
(If Yes Please explain)
- Has this person ever had an ASBO? Yes / No
(If Yes Please explain including if it is still in force or when it ran out)
- Use of drugs (including prescribed and/or illegal substances) and use of alcohol
Yes / No
(If Yes Please explain)- Mental Health Issues & any changes (please include outcome of any assessment, information about treatment) Yes / No
(If Yes Please explain)
- Loss of any previous/ existing accommodation Yes / No
(If Yes Please explain)
Person who filled out the above Risk Assessment Details…(Please state if you are the Referrer)
Name………………………………………………………….
Occupation………………………………………..
Address…………………………………………………………………………………………………..
……………………………………………………………………..
Phone No……………………………..Fax…………………..Email………………………………….
Has known the Applicant for……………………
In what capacity do you know the Applicant…………………………….
I sign to say the above details are to the best of my knowledge correct
Signed………………………………………………… Date:……………………………………………………..
To Be Completed By The Young Person Being Referred:
What do you think you will gain from completing This Tenancy Training Course?
______
Referrer’s Details/Agency Information (if applicable):
Referral Agency ______
Worker’s Name ______
Address ______
______
______
Telephone Number ______Fax Number ______
Young Person’s Consent:
I understand that this referral has been made and I am happy for this information to be passed on to Chapter 1 ‘The Limes’
Signed ______Print Name:______
Date ______
PLEASE COMPLETE DATA PROTECTION DECLARATION AND EQUAL OPPORTUNITIES FORM AND RETURN TO
· Chapter 1 The Limes 76 Daisy Bank Rd, Victoria Park Longsight M14 5GL
· or Email to
Chapter 1 The Limes
The Delta Tenancy Training
Name :…………………………………………….
N.I: ……………………………….……………..
Address :………………………………………….
…………………………………………..
……………. ……………………......
Data Protection Act 1984
Declaration
In accordance with the requirements of the Data Protection Act (1984), I have agreed that information held by the following organisations may be made available to, and discussed on my behalf by my Tutor at The Limes, in order to assistme in my Tenancy Training.
ORGANISATION / SIGNATURE / DATEMANCHESTER HOUSING
MANCHESTER MOVE
OTHER HOUSING PROJECTS/HOSTELS
COUNCIL TAX
OTHER - PLEASE SPECIFY;
ALL OF THE ABOVE
EQUAL OPPORTUNITIES MONITORING FORM
Please help us to monitor equal opportunities by filling in this form. This will help us to make sure that the service we provide is accessible and open to all people who may need our service. If you have any questions about the form, please ask any member of staff, who will explain..
How would you describe yourself? (Please tick boxes)
Are you Female Male Trans Date of Birth ____ / ____ / ____
Ethnic Origin
African Caribbean Black British Other Black
Bangladeshi Indian Pakistani Other Asian
White British Irish Other White
White & Black African White & Asian White & Other Mixed
Black Caribbean
Chinese Other Rather not say
Please state if not on the list ______
Sexuality Disability
Lesbian I have a disability
Gay Man I do not have a disability
Heterosexual (straight) Rather not say
Don't know Refugee
Bisexual I am not a former Asylum Seeker
Rather not say I am a former Asylum Seeker
Rather not say
First Language ______Second Language ______
Are you homeless? Yes No Have you ever become homeless? Yes No
Are you pregnant? Yes No Do you have any children? Yes No
Have you ever been in care or lived with Foster Parents? Yes No
If yes, was this before you were 16? Yes No
After you were 16? Yes No
Are you still in care? Yes No
If yes, which Social Services Department were involved? ______
Chapter 1 is registered under the Data Protection Act. Thank you very much for taking the time to fill in this form
From time to time we may take photographs of you whilst you are on the course at the Limes, these will be for educational or promotional purposes in any type of our media including it’s website. The photographs will not be used for profit, I understand that I will not be paid or rewarded for providing this authorisation.
I agree to having my picture taken
I do not agree to having my picture taken
Signed ………………………………………………..Date…………………………………..
Referrals’ Name:………………………………..9