General Referral and Application Form for Housing Related Support Services

PART A – APPLICANT DETAILS

Single Assessment Form

General referral and application form for housing related support services.

Completed forms should be emailed to

Applicant Name:

Permission to Share Information/Make Enquiries:

Amicus Trust aims to provide a single point of access to a range of short term housing related support services across England. In order to do this, we need to ensure that as much information as possible can be shared between agencies about your needs. All information shared will be treated as confidential and shared only with those who need it (see Data Protection statement below).

Statement of Agreement:

I understand, and agree, that in order for my application to be considered by service providers, it will be necessary for these organisations to have access to the information contained within this form.

I also accept and agree that it may be necessary for these organisations to contact other agencies who work with me so that they can get a better understanding of my individual needs.

I confirm that the information in this form is correct and I understand that providing false information may lead to my application being declined or an offer of accommodation being withdrawn.

Signed:
Date:

Please note that if the Statement of Agreement is not signed by the applicant, the service provider may not accept it. If someone is in custody and therefore unable to sign, the referrer must discuss this with the support provider directly.

Confidentiality - Data Protection Act 1998

Please note that your personal details supplied on this form may be held and/or computerised by Amicus Trust and the relevant Local Authority for the purposes of assessing your housing related needs. To do this, these details may be disclosed to those organisations listed on this form, other local authorities, health agencies, and other organisations or individuals with whom the Council needs to liaise.

Your personal details held by Amicus Trust will be safeguarded and will not be divulged to any other individuals or organisations for any other purposes.

Note for Referring Agencies:

In sending this form by e-mail the referring agency confirms that the agency holds the applicants written agreement (above) on file. A copy of this signatory page should be made available to Amicus Trust when requested.

Please also ensure that as many areas of the form are completed as possible – forms which are incomplete or lacking in detail may be returned to the referrer for further completion.

Date of Birth:
Age: / Gender:
Male 
Female 
Other  / Have you ever been in care? Yes  No 
Do you have a leaving care worker? Yes  No 
If yes please give their name below:

If you are 16 or 17, you are entitled to have a ‘Child in Need’ assessment carried out for you.

If you have already had this assessment please tick the box 

If you would like to have an assessment your details can be passed onto Local Authorities Council’s ‘Children and Young Person’s Services’. If you do not want your details to be passed on so that an assessment can be arranged for you, please tick the box 

Which of these best describes your current situation?

Married  Single  Divorced  Widowed With a partner  Other 

Do you preferred to be referred to as;

Mr  Mrs  Miss  Other – please give details

Contact number: Telephone/Mobile/Text
Email address: / National Insurance number:

Alternative Contact/ Next of Kin

If we are unable to contact you on the number above, is there someone else we can call to reach you e.g. a friend, family member, social worker etc? Please include the person’s name and number below:

Name: Contact number:

Please tell us what this person’s relationship to you is e.g. friend, parent, support worker etc:

Do you need an interpreter? Yes  No 

If yes please state which language is needed (including British Sign Language):

Do you need any help with reading and writing? Yes  No 

Please take a few moments to check that you have entered the correct information on this page as people will need to use this information to contact you to arrange interviews.

Immigration Status (please mark with an ‘X’)

UK National / Asylum Seeker Awaiting Decision
Discretionary Leave to Remain / EEA National Currently Working
EEA National financially self supporting / EEA National in UK Studying
EEA National receiving welfare benefits / Husband/Wife Sponsorship
Humanitarian Protection / No recourse to public funds
Indefinite Leave to Remain / Refugee
Study Visa / Work Visa(s)

Current Address

Which area do you live in?

Bedford BoroughCentral Bedfordshire Milton Keynes 

Leicester CorbyWellingborough 

Current Address: Time Spent at this Address:

Years
Months

If you have no current address, please give your most recent address:

Time Spent at this Address:

Years
Months

Have you visited your local authority/housing office for housing advice or to discuss your housing options?

Yes  No 

Type of current accommodation: (please mark with an ‘X’)

With Parents / Hospital
With Relatives / Prison
With Friends / Youth Offending Institute
Supported Housing / Children’s Home
Supported Lodgings / Foster Care
Hostel/Shelter / Approved Bail Hostel
Sleeping Rough / Rehabilitation Centre
Bed and Breakfast / Residential Care
Local Authority/Council / Sheltered Housing
Housing Association / Armed Forces
Private Rented / Travellers Site
Owner Occupier / Tied home or rented with job
Other – please give details:

Financial Situation

Do you have debts?

Previous Rent ArrearsYes  No Around: £

Other DebtsYes  No Around: £

Income Type (please mark with an ‘X’)

JSA/Income Support / Tax Credit – Family
Wages/Salary / Housing Benefit
Incapacity Benefit / Disability Working Allowance
DLA (mobility) / DLA (care)
Child Benefit / Severe Disability Allowance
Pension / Occupational Pension
State Pension / Statutory Sick Pay
Tax Credit - Working / PIP (Personal Independent Payment)
ESA (Employment Support Allowance) / Other
Universal Credit

Source of Referral:

Agency Name:
Referrer Name:
Address1:
Address2:
City:
County:
Post Code:
Contact No:
Alternative Contact No:
Email Address:

Veterans THIS SECTION IS TO BE COMPLETED BY VETERANS ONLY

Service: / Regiment, branch, corps:
Service No:
Rank: / Date enlisted:
Date discharged:
Reason for discharge:
Were you an Early Service Leaver (ESL)?: 
If yes, were you given an ESL briefing:
Navy / 
R.A.F. / 
Army / 
Merchant Navy / 
T.A. / 
Other / 

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PARTB – SUPPORT NEEDS

In your own words, please can you tell us why you feel you need this kind of service?

Primary reason for needing Housing Related Support at this time (please mark ONE ONLY with an ‘X’)

Family Dispute
Leaving Prison
Leaving Care
Pregnancy
Left/Leaving Abusive/Violent Situation
Move-On form Supported Accommodation
Leaving Temporary Accommodation
Relationship breakdown
Told to Leave by Landlord
Eviction Court Order (arrears)
Eviction Court Order (anti-social behaviour)
Eviction Court Order (other)
Other – please give details

Please provide any further information you can regarding your current housing situation (e.g. still living in current accommodation, been asked to leave by parents, homeless, prison release date, fleeing domestic violence etc)

If you had a previous tenancy in your name what was your reason for leaving?

Financial – Rent Arrears

Financial – Other

Anti-Social Behaviour

Breakdown in Relationship

Left Voluntarily

Do you have any Physical Disability issues or needs which need to be considered?

Yes  No 

If Yes Please include any problems you may have with sight, hearing or general mobility.

Do you have any Cultural or Gender Specific needs which need to be considered?

Yes  No 

If Yes Please give details:

Is there currently a support/care/pathway/CPA* plan in place? Yes  No 

If yes, please either attach a copy of this plan, or give details of someone who can be contacted to discuss the plan (If this is not possible, please explain why below).

*Care Programme Approach

Education, employment and training: (please mark any that apply to you with an ‘X’)

Working full time (24 or more hours per week)
Working part time
Job seeker
Government training/New Deal
Not seeking work
Unable to work (due to sickness or disability)
Full time student
Part time student
Thinking of starting a course or training
Retired

Personal Health & Well-being:

The purpose of this section is to help potential support providers understand what problems you may be experiencing or may have experienced in the past, so that they can consider the sort of support or assistance that you may need.

Have you had, or do you currently experience any of the following? (please tick all that apply and provide additional details below)

Has the client previously or currently experienced Drug misuse? / Yes / No
If Yes, Please give details of any treatment (including medications) the client has or is receiving for Drug misuse:
Is the client subject to a Drug Rehabilitation Requirement (DRR)? / Yes / No
Has the client previously or currently experienced Alcohol misuse? / Yes / No
If Yes, Please give details of any treatment (including medications) the client has or is receiving for Alcohol misuse:
Has the client previously or currently experienced Mental Health concerns? / Yes / No
Has the client previously or currently Self-Harmed? / Yes / No
Has the client previously or currently experienced Physical Health concerns? / Yes / No
Has the client previously or currently experienced Violence or Aggression? / Yes / No
If Yes, please give details of any treatment received for Violence or Aggression:
Is the client subject to an Anti-Social Behaviour Order? / Yes / No
Has the client previously or currently had Anger Management issues: / Yes / No
Has the client previously or currently been receiving treatment for Anger Management?
Has the client previously or currently experienced an Eating Disorder? / Yes / No
Has the client previously or currently any Social or Emotional concerns? / Yes / No
Has the client previously or currently experienced any Learning Difficulties? / Yes / No
Did the client have a statement of special education need while at School? / Yes / No
Did the Client attend a Special School? / Yes / No
Please give details:
Has the client previously or currently experienced problems with Memory Loss? / Yes / No

Risk Assessment

Is there a risk assessment in place in relation to any of the above areas? Yes / No

If ‘Yes’ please attach a copy of the risk assessment or give details of someone who can be contacted to discuss the risk assessment (If this is not possible, please explain why below).

Additional Details: If you have answered ‘Yes’ to any of the above, please give brief details of the support or service that you are currently receiving or accessing. Please include details of the individual or agency providing the support or service.

Children or Dependents

Do you have any Children?Yes  No 

Do you have any dependents or children who are living with you, or are expected to live with you?

Yes  No 

Please give name and Date of Birth of each child

Name / DOB / Name / DOB

Please give details of any special requirements / considerations:

Do any of your children have, or have they had a Child Protection Plan or Children in Need Plan?

Yes  No 

Are you currently pregnant*? (If yes please give your due date below)

Yes  No  Due date:

*Please note that you may be required to provide proof of pregnancy.

Do you have a CAF (Common Assessment Framework) in place?

Yes  No  Not sure 

Do you have any pets? Yes  No 

If YesPlease give details

Please note that most supported housing services do not allow you to keep larger pets such as cats and dogs.

Previous Addresses:

Address
Please give details of your previous addresses in the last 2 years, including dates mm/yy, from and to / Was this Supported
Accommodation? (including Floating Support) / Accommodation type
i.e. with parents, with friends, Council/RSL tenancy, owner- occupier, slept rough, private rented, hostel , supported housing etc
Please note: You do not need to include addresses where you stayed for only 5 nights or less.

Agency Referrals

Current or recent (within the last 12 months) involvement with other Agencies:

Agency / Named Worker/Contact / Tel No. / E-mail
Primary Care services:

• GP
• Health Visitor
• Midwife
• District Nurse
• Homeless service
• Hospital

Adult Social Services
Day Centre(s)
Children’s Social Services
Sure Start/Children’s Centre
Sexual Health Service
Family Support/Family Centre
Connexions
Police
Probation
Youth Offending Service
Drug & Alcohol Treatment services
Mental Health Services/Community MH Team

Continue….

Agency / Named Worker/Contact / Tel No. / E-mail
Local Housing Department/Team
A current housing related support provider (see list at front for examples)
Citizens Advice Bureau (CAB)
Other service provider / agency (e.g. employment services, advice services, voluntary services etc)

Convictions and Offences:

If you have any unspent convictions (as defined by the Rehabilitation of Offenders Act 1974) please list them below.

Offence Committed / Conviction / Conviction Date

Cases pending: Do you currently have any cases pending? Yes  No 

Cautions: Do you currently have any cautions in place? Yes  No 

Arson: Have you ever committed an act of arson (setting fire to things)?Yes  No 

Sexual Offences: Have you ever been committed of a sexual offence? Yes  No 

MAPPA: Are you subject to MAPPA arrangements? Yes  No 

If yes, are you subject to MAPPA level 1, 2 or 3?

Accommodation Needs

Which area(s) would you prefer to find accommodation? (tick all that apply)

Bedford BoroughCentral BedfordshireMilton Keynes

LeicesterCorbyWellingborough

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PARTC – REFERENCES

If you have selected a service which requires references, you must complete this section (see service list on page 2 for details of these services)

References:

Some services require a reference from someone who knows you, who will be able to give feedback about you. Most will ask you for details of two people (or ‘referees’) that can provide this sort of feedback.

One of these could be a family member or friend the other would need to be a professional person who knows you for example, a social worker or connexions advisors, a teacher, medical person or someone from the police or youth offending service.

If this information is not provided, the service(s) you have chosen may not be able to process your application. (For details of services requiring references, please see note on page 2 of this form)

Professional Referee:

Name
Job Title
Agency/Team
Address
Postcode
Contact Number
Email

Personal Referee:

Name
Address
Postcode
Contact Number
Email
Is this person a relative or friend?

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PARTD – INFO FOR APPLICANTS

This short section contains information for all applicants. Please make sure that you read this information.

Additional Information for Applicants - Please read this carefully

If you are invited to attend an interview or meeting with a provider who has received your application, they may ask you to bring along the following additional information;

• A form of ID: This would ideally include some form of ID with a photo e.g. passport or photo driving licence, but other forms of ID may also be acceptable. The service provider will be able to give more details of what to bring along with you on the day.

• Proof of income: This may include pay slips, proof of benefit entitlement or pension information, or a letter from the Leaving Care Team.

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PARTE – FAIR ACCESS MONITORING

All applicants are asked to complete this section.

Ethnic Monitoring: (please mark with an “X”)

Please note that this information is for monitoring purposes only.

White English / Welsh / Scottish / Northern Irish / British

White Irish

Any other White background

Caribbean

White & Black Caribbean

African

White & Black African

Any other black /African /Caribbean background

Chinese

Pakistani

Indian

Bangladeshi

Any other Asian background

White & Asian

Gypsy or Traveller

Any other mixed / multiple ethnic background

Arab

Any other ethnic group - please give details ………………………………………….

Prefer not to answer

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PARTE – GENERAL INFO

Rehabilitation of Offenders Act

The Rehabilitation of Offenders Act 1974 enables some criminal convictions to become 'spent', or ignored, after a 'rehabilitation period'.

A rehabilitation period is a set length of time from the date of conviction. After this period, some ex-offenders may not need to mention their conviction when doing things like applying for accommodation or a job, although for some jobs you may still be asked to disclose ‘spent’ convictions e.g. if you were applying for a job working with children or vulnerable people.

The Act is more likely to help people with few and/or minor convictions. People with many convictions, especially serious ones, may not benefit from the Act.

Rehabilitation Periods

The length of the rehabilitation period depends on the sentence given - not the offence committed. For a custodial sentence, the length of time actually served is irrelevant: the rehabilitation period is decided by the original sentence. Custodial sentences of more than 2 1/2 years can never become spent.

The following table helps explain rehabilitation periods and when sentences become spent (i.e. do not need to be declared when applying for accommodation, a job etc.):

Sentence / Rehabilitation Period
People aged
18 or over
when convicted / People aged
17 and under
when convicted
Prison sentences of 6 months or less / 7 years / 3 1/2 years
Prison sentences of more than
6 months to 2 1/2 years / 10 years / 5 years
Borstal (abolished in 1983) / 7 years / 7 years
Detention centres (abolished in 1988) / 3 years / 3 years
Fines,
probation,
compensation,
community service,
combination action plan,
curfew orders,
drug treatment and testing,
and reparation orders / 5 years / 2 1/2 years
Absolute discharge / 6 months / 6 months

With some sentences the rehabilitation period varies:

Sentence / Rehabilitation Period
Probation, supervision, care order,
conditional discharge or bind-over / 1 year or until the order expires (whichever is longer)
Attendance centre orders / 1 year after the order expires
Hospital orders (with or without
a restriction order) / 5 years or 2 years after the order expires
(whichever is longer)
Referral Order / Once the order expires

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