MARY SEACOLE HOUSING ASSOCIATION LIMITED

12 Cardiff Road, Luton, Beds, LU1 1GQ

Tel: 01582 415651

External Referral Form for Supported Accommodation

(Supported Accommodation for people aged 18-65 is only available for those who have support needs)

NAME OF REFERRED
PERSON: / REFERRING AGENCY:
TEL NO: / REFERRING OFFICER:
MALE/FEMALE: / STATUS:
ie: Single / Married / DATE OF ADMISSION:
CURRENT ADDRESS:
LAST KNOWN ADDRESS:
TELEPHONE NUMBER: / DATE OF BIRTH: / ETHNIC ORIGIN:
NI. NUMBER: / DEPENDANTS/PARENTS
NEXT OF KIN:
EMPLOYMENT DETAILS:

BANK DETAILS

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YES

NO

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BENEFITS

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Job Seekers Allowance (JSA)

Incapacity Benefit

Disability Living Allowance

Income Support

EMA

Social Services Allowance (SS)

Government Training

Other Benefits (please specify)

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______

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FORMS OF IDENTIFICATION - ESSENTIAL (2 forms of identification are required)

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Passport

Birth Certificate

National Insurance Card

Driving Licence

Letter from Home Office

Letter from parents stating reasons for leaving home

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RISK ASSESSMENT

RISK FACTORS / RISK (HIGH/MED/LOW) / COMMENT
Mental Health
Offending Behaviour
Aggressive Behaviour
Sexualised Behaviour
Drug use/misuse
Please give details of other agencies involved with you or your client:

OTHER AGENCIES THAT MAY HAVE OFFERED YOU SUPPORT WITHIN THE LAST 2 YEARS

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Drug

Hospital

Other Please Specify:

Probation

Hostels

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…………………………………………………………………………………………………..

YOUR SUPPORT NEEDS:Yes No

  1. Maximise income,

including receipt of right benefits

  1. Reduce overall debt
  1. Obtain Paid work
  1. Participate in chosen training and/ or education,

and where applicable, achieving

desired qualifications

  1. Participate in chosen leisure/ cultural/ faith/

informal learning activities

  1. Participate in chosen work like/ voluntary/

Unpaid work activities

  1. Establish contact with external service/

Family/ friends

  1. Better manage physical health
  1. Better manage mental health
  1. Better manage substance misuse
  1. Better Manage independent living

as a result of assistive technology/

aids and adaptations

  1. Maintain accommodation and avoid eviction
  1. Comply with statutory orders and processes

(in relation to offending behaviour)

  1. Better manage self harm, avoid causing harm to

others, minimise harm/ risk of harm from others

  1. Greater choice and/ or involvement and/ or
  2. control at service level and within

the wider community

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BRIEF REASON FOR REFERRAL:
REASON FOR HOMELESSNESS
ANY OTHER INFORMATION:

I ……………………………………………... apply for supported accommodation at Mary Seacole Housing Association Limited and understand that should I be offered accommodation, I will be expected to be honest, truthful, trustworthy and respectful. I must also be willing to negotiate a Support Plan and work with the staff of Mary Seacole, to achieve my personal goals within the Support Plan.

Signature:Date:

Person Referred

Signature:Date:

Referring Officer

MARY SEACOLE HOUSING ASSOCIATION LTD

CLIENT CONFIDENTIALITY &INFORMATION SHARING CONSENT AGREEMENT

NAME:

NATIONAL INSURANCE NO.

ADDRESS:

Any information which is recorded by Mary Seacole Housing Association about you is available for you to see. Copies of the Support Plan will be given to you.

Should you wish to see any other papers please discuss access arrangements with your Support Worker.

In order to provide a comprehensive and quality service to meet your needs, it may be necessary to obtain information from other statutory and voluntary agencies and to share information with them, including copies of documents on your file.This includes the uploading of information to Luton Borough Council secure web based system Capita.

Please sign here to indicate your agreement.

I DO/DO NOT AGREE

Signed

Date

□ Client advised about complaints, procedure and access to file

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