Manchester Shelter Referral Form

Manchester Shelter Referral Form

Service Criteria:

• a self-defining woman of Muslim faith;
• over the age of 16;
• in need of the Services provided at the Premises;
• homeless or at risk of homelessness;
• in need of low to medium levels of support;
• willing to accept a package of support;
• willing to comply with terms of the licence agreements and/or any house rules;
• willing to accept that the accommodation based service will normally be available for 12 weeks only in which time we will aim to move the Occupant onto more suitable accommodation and;
• Must also have recourse to claim benefits or work in the United Kingdom.

Please note that this service is not able to accommodate children.

Please return the completed form to

Referring organisation / Date:
Referring workers name
Contact details
Office number
Mobile number
Email address
Name of Client:
Date of birth: / Gender: Female
National Insurance number: / Mobile number:
Is it safe to use this number: Yes / No
Race:
Ethnicity: / Country born in:
Preferred Language:
Wheelchair use:
Language support: / Borough last lived in:
Borough connection:
Immigration Status: / Pregnant: Yes/No
Significant
contacts / Name / Tel number / address / Will this person provide
support after the move?
Next of Kin
Doctor / GP
Family
Other
Friend
Benefits
Is client entitled to Benefits? / If yes, is client in receipt of Benefits?
Which benefit? / Which Benefit Office:
If none, why? / Any other source of income?
What ID does client have? / Birth Certificate
Diagnosis / Currently / In the last 6 months / Never
Depression
Anxiety
Eating disorders
Hallucinations
Delusional thoughts
Suicidal thoughts/ Self
harming.
Panic attacks
Aggressive behaviour
Memory problems
forgetfulness
Dressing inappropriately
Wandering aimlessly
MENTAL HEALTH
Please state: Are you currently experiencing mental health issues? Or have a history of mental health illness?
(Please note these can be diagnosed or undiagnosed.)
YES/NO
Has the client ever experienced any of the following (diagnosed or undiagnosed), please tick were appropriate:
Have been diagnosed with a mental health illness? YES/NO
Please state your diagnosis: ______
Are you currently on any medication? YES/NO
Please list the medication you are currently taking: ______
Referring worker’s comments/actions:
PHYSICAL HEALTH
Please state: Do you experience physical health illness/es or condition/s? YES/NO
Please list any medication you are currently taking?
Does client have any mobility issues?
e.g. Climbing stairs? / Details:
FURTHER INFORMATION
To support referral:
Any History of Domestic Violence or Abuse?
Current areas of risk?

Housing History

Please record a housing history going back at least five years, starting with current accommodation and work back.

Dates / Address
(include periods sleeping rough) / Type of
accommodation* / Reason
for leaving
From / To
Present / Current Residence

*e.g. hostel (long or short stay), night shelter, council housing, housing association, with family, friends or partner, local authority care, detox/rehab, owned own home, hotel/ B&B, squatting, privately renting, hospital, prison, sleeping rough

Details of housing history
Please provide details of significant events in your housing history, including eviction, abandonment,
arrears, and time spent in prison, etc. Please think about any periods of stability and why this worked
well.
SIGNED BY REFERRING WORKER: / DATE:……………………

Outcome of referral

1