REFERRAL FORM

Pathways to Independence provides semi-independent accommodation. It is non-residential accommodation, and we do not have sleep-in staff providing supervision after 5pm or before 9am.

Young people should have reached a suitable level of independence before they are referred to our organisation. This referral is for a room in a house with shared facilities, and for support towards fully independent living. We are also able to provide single units in some cases where this would be appropriate.

Referrals do not need to have a connection with the area to which they are being referred.

Please fill in as much of the form as possible. Any sections marked with an asterisk must be filled in. Failure to fill them in may result in the form being returned or referral being delayed.

  1. Details of Referrer
  1. Details of young person
  1. Housing History

Please give details of this young person’s last three addresses
Address / Type of Accommodation / Date moved in / Date moved out / Reason for leaving

If this young person has ever been evicted, please give details of the organisation which evicted him/her below, and provide details regarding the eviction:

  1. Suitability

Please use this sheet to tell us why you are referring this young person to Pathways. Please consider:

  • What support you think they will need
  • What challenges you think they will face
  • How long you intend them to be at the placement

RISK ASSESSMENT

Please give as much information as possible. It is important to receive a detailed holistic assessment of the young person’s needs and risk factors in order for the appropriate level of support to be provided. Details given will not necessarily exclude a young person from being offered a placement

Does this young person have a history of any of the following (an opportunity to provide details is provided below):

Behaviour / Yes/No
Arson
Physical Violence
Sexual Offences
Damage to Property
Any information given relating to racial or ethnic origin, physical or mental health and criminal convictions constitutes sensitive data as defined by section 2 of the Data Protection Act 1998. I consent to the information given by me, including such information as constitutes sensitive data, being used, in accordance with the principles of the Data Protection Act 1998, for the purpose of processing my application and if successful in gaining a placement, for delivering services to me.
The above information is accurate and true to the best of my knowledge:
Signature of applicant:
Signature of referrer: / Date:
Date:

Please send completed referral form together with any relevant reports or assessments to:

07702 516421

Please feel free to get in touch if you require any further information.