KENT HOUSE Hightown Praetorian and Churches Housing Association

REFERRAL FORM

Date

D D M M Y Y

Main/Key assessor

Client Details:

Surname
Forenames
Date of Birth

D D M M Y Y

Sex / M / F / Age
N.I Number

Current Address/Contact Place: ...... ….

......

Telephone Number......

Person to be contacted in case of emergency:

a) Name: ...... …......

b) Relationship: …......

c) Contact Address: ……………......

......

d) Contact Telephone Number: ......

Where was client born and brought up? ………………………………………….

Place of last stable residence Town/County: ………………..………………………..

Does the client have a current connection with St Albans YES / NO

If yes, please describe……………………………………………………………………..

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

Referring Agency

Name & address of agency......

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

Email:

Phone:

Type of agency......

Is the client able to provide a housing reference/supporting letter? YES / NO

If yes, from whom? ………………………………………………

(Please advise client that any references/letters should be provided a.s.a.p. to support their application)

Contact Agreement

Please ask client to sign below to give Martin House staff permission to contact referring agency and third parties referenced in the referral for any further information relating to this referral.

I consent that information about my history and housing history and any risk of harm to myself or others can be shared with Martin House.

Signature of client: ……………………………………………………………………….

Asylum Seeker/Refugee Status

(If applicable, relevant home office documents must be provided)

Is the client an asylum seeker? YES / NO

Has client had a Habitual Residency Test (HRT)? YES / NO

(HRT is a benefits assessment. For entitlement(s) an Individual must have lived within the UK for 5 years or more).

What was the outcome of the HRT?

…………………………………………………………………………………………

When is next HRT due?

M M Y Y

Benefits

Is client on benefits? YES / NO

Type of benefit: ……………………………………………………………………………

Amount: £ …………… Weekly Fortnightly Other 

Day benefit paid ……………………… Payment Method: BANK / GIRO / BOOK

Since when has benefit been in payment? ………………………………………….

Which office is benefit currently paid from? ……………………………………………

Does the client have any current deductions from there benefit? YES / NO

If yes, what for? ……………………………………………………………….

(If an interview is offered, the client must bring proof of any applicable benefits)

Identification

Does the client have ID? YES / NO

Describe:

…………………………………………………………………………………………

(When attending interview, the client must bring two forms of identification, preferably birth certificate/passport/driving licence/bank details etc)

Employment

Is client currently employed? YES / NO

If yes please give name and address of employer:

………………………………………………………………………………………………

Clients Earnings: £ ……………. Weekly / Monthly / PA

(Client must provide last two wage slips if currently employed)

Work History

Please give details below of any previous employment, starting with the most recent. Please include employer’s name and location, and dates worked from/to. Please also give reason for leaving.

…………………………………………… …………………………………………………

Other sources of income:

If client is not receiving benefits and is not currently employed, please indicate below any other sources of income.

Weekly Basis

1. Borrowing from friends/family / £
2. Begging / £
3. Crime/criminal activity / £
4. Sex industry / £
5. Other (describe). ……………………………………………… / £

Physical Health Assessment

Registered with GP? YES / NO

If yes, please provide name and address of GP: ………………………………………

……………………………………………………………………………………………….

Please describe any past or present medical conditions/prescribed medication

1)...... Medication: ……………………………….

2)...... Medication: ……………………………….

3) ……………………………………... Medication: ………………………………..

4) ……………………………………… Medication: ………………………………..

Medication prescribed by:

GP Out patient clinic

A & E department Nurse practitioner

Hospital Doctor Other

Is the client registered disabled? YES / NO

Comments

…………………………………………………………………………………………………

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

Family and Current Relationships Assessment

(In this section, please indicate whether the client/relative are in contact, whether they live in local area, and whether there are any significant issues affecting the client e.g court proceedings, CSA etc. Please do not leave sections blank)

Describe relationship with:

1) Natural Parents and/or Surrogate Parents (e.g. Foster Parents, Guardians, Adoptive Parents, if any):

....…......

…......

2) Siblings (including stepsiblings):

…......

..……......

Ex - Partners:

…......

……......

Current Partner:

…......

5) Children & Step Children:

…...... ……..

………………………………………………………………………………………………

Education

Client currently in F/T education? YES / NO

If YES, please give name and location of course: ………………………………………...

If NO, please complete section below.

At what age did client leave school? …………………………………….

Schools/colleges attended: (please give dates)

………………………………………………………………..

………………………………………………………………...

………………………………………………………………..

Please list any qualifications gained:

………………………………………………………………..

………………………………………………………………...

…………………………………………………………………

Reading and Writing difficulties (Do not leave blank)

 None  Reading difficulties  Writing difficulties

 Both reading and writing difficulties

Has the client ever been assessed as having any special educational needs?

YES / NO

Comments

……………………………………………………………………………………………..

………………………………………………………………………………………………

Childhood (Please describe below any important aspects of childhood e.g. bullying/abuse etc)

…………………………………………………………………………………………………

Care Record

Has client been in care/foster care? YES / NO

Age when first went into care/foster care: …………………………

Age when last left care/foster care: ………………………………..

Comments: …………………………………………………………………………………….

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

Housing/Homelessness Assessment

Has the client applied to local authority housing? YES / NO

If YES please give housing reference number: ………………………………..

Has the client applied to any other Housing Associations? YES / NO

If yes, which? ……………………………………………………………………….

………………………………………………………………………………………..

Is the client currently:  Statutorily homeless under Housing Act 1996

 Not Homeless  Other Homeless

Describe below in detail homelessness situation prior to arriving at service:

......

Housing History: (last five years)

Housing / Dates
(From - To): / Rent Arrears / Reason for Leaving
£
£
£
Housing
continued / Dates
(From - To): / Rent Arrears / Reason for Leaving
£
£

Where rent arrears are applicable, has the client made any repayments?

YES / NO

Please give details about rent repayment plans

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

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

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

Have you ever had your own tenancy? YES / NO

Describe below: (Please include dates/details of rent arrears)

………………….…......

......

...... …

......

…………………………………………………………………………………………..

Have you stayed in a hostel or supported housing? YES / NO

Have you ever been evicted from a hostel or supported housing? YES / NO

Comments: …......

...... ……

…………………………………………………………………………………………………

……………………………………………………………………………………………….

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

Has the client ever lived in any of the types of accommodation listed below?

YES/ NO (If yes, please tick relevant box)

 Army /  Detention Centre
 Prison /  With Friends
 Hospital /  Tied Accommodation (with Job)
 Probation Hostel /  Shared House/Flat
 Youth Custody Centre /  Other
 Live in Job

Comments:

......

SUPPORT NEEDS (please tick the areas in which the client needs support)

 Managing Money /  Anger Management
 Completing Forms etc /  Resettlement
 Personal Hygiene /  Survivor of Domestic Violence
 Seeking Employment /  Survivor of Sexual Abuse
 Education/Training /  Help With Benefits
 Social Skills /  Immigration Status
 Understanding Boundaries /  Other
 Cooking
 Communication

Comments: …………………………………………………………………………………..

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

…………………………………………………………………………………………………

......

………………………………………………………………………………………………….
Drug Use Assessment

Is the client currently using, or have they used in the past, any of the following?

 Heroin
 Cocaine
 Crack
 Cannabis
 Amphetamines
 Glue / Solvents / Gas
 Ecstasy
 LSD
 Prescribed Methadone
 Other

Please give details:………………………………………………………………………..

……………………………………………………………………………………………….

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

……………………………………………………………………………………………….

Is the client currently accessing any drug support/treatment services? YES / NO

If yes, please give name of agency and describe type of service accessed (e.g. counselling/detox etc). A copy of any recent risk assessment should be attached.

…………………………………………………………………………………………….

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

Any other addictions

………………………………………………………………………………………………

……………………………………………………………………………………………….

Alcohol Use Assessment

How often does the client drink alcohol? ………………………………………….

When client drinks, what is a typical amount? …………………………………….

Where does client’s drinking normally take place? ………………………………

Does client drink alone or socially? ……………………………………………….

Does client ever binge drink? ………………………………………………………

At what age did client first drink alcohol? …………………………………………

Has client ever felt alcohol use was out of control? ………………………………

Is the client currently accessing any alcohol support/treatment services?

YES / NO

If yes, please give name of agency and describe type of service accessed (e.g. counselling/detox etc). A copy of any recent risk assessment should be attached.

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

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

Mental Health Issues Assessment

Does the client ever experience, or have they ever experienced, any of the following?

(Please tick all that apply and give details overleaf where applicable)

 depression /  panic attacks
 anxiety /  memory problems
 bipolar disorder /  aggressive behaviour
 eating disorder /  suicidal thoughts
 hallucinations /  suicide attempts
 delusional thoughts /  self harm
 phobias /  Other

Details + Current Medication & Dose: ………………………………………………………………………………………………….

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

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

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

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

Is the client currently accessing any mental health support treatment services for any of the issues described above?

YES / NO

If yes, please give name of agency, type of service and how often the client accesses this service at present. Please include any previous use of these services.

(Please note: copies of any completed risk assessment/CPA must be provided at referral stage)

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

Mental Capacity Assessment & Deprivation of Liberty Safeguards

Does the person currently or have they previously lacked capacity in any area of their life?

YES / NO

If yes, please state the areas in the space provided below:

………………………………………………………………………………………………

Has a recent formal mental capacity assessment been undertaken? YES / NO

If yes, please attach a copy

What support is provided to empower and protect the person in the area where they are deemed to lack capacity?

…………………………………………………………………………………………………

Is this an ongoing need? YES / NO

Are there any existing restrictions that deprive the person of their liberty?

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

Are there any pending Deprivation of Liberty Safeguards or Court of Protection applications?

…………………………………………………………………………………………………

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

What restrictions do you feel should be in place if the person moved into Martin House.

…………………………………………………………………………………………………

Criminal Activity

Has client ever been in trouble with the police - arrested/cautioned? YES / NO

Has client ever been on probation/YOT license? YES / NO

Has client ever been in prison or young offenders institute? YES / NO

Has client ever been convicted of arson? YES / NO

Has client ever committed any violent offences? YES / NO

Is client on the sex offender’s register? YES / NO

If yes to any of the above, please give details. Please include dates, age of client at time of offence, nature of offence, names and locations of any relevant probation/Y.O.T. workers.

(Copy of any completed risk assessment must be provided at referral stage)

…………………………………………………………………………………………………

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

Mini Risk Assessment

(Please note: an interview cannot be offered to the client if this section is not fully completed and signed by the referring officer)

Has the client shown any current or previous tendency towards aggressive, threatening or abusive behaviour?

YES / NO

Details: ………………………………………………………………………

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

Are there any issues for the client when working alone with staff?

YES / NO

Details……………………………………………………………………………..

…………………………………………………………………………………......

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

Issues when working with opposite sex staff?

YES / NO

Details……………………………………………………………………………..

……………………………………………………………………………………………………

Referring Officer: (Print Name)…………………………………………….

Email referring officer:

Phone referring officer:

Organisation & Address:

Signature of Referring Officer: ………………………………………………

Please ask the applicant to indicate which box best describes them (optional)

Gender / Male o / Female o / Trans Gender o
Sexual Orientation / Heterosexual o / Lesbian o / Gay Man o
Bisexual o / Rather not say o
Religion / None
o / Christian
o / Buddhist
o / Hindu
o / Jewish
o / Muslim
o / Sikh
o / Other
o
Marital Status / Single
o / Married
o / Divorced
o / Separated
o
Ethnic Origin / White British
o / White Irish
o / Any Other White Background
o / Caribbean
o / African
o / Any Other Black Background
o
Indian
o / Pakistani
o / Bangladeshi
o / Any Other Asian Background
o / White & Black Caribbean
o / White & Black African
o
White Asian
o / Other Mixed
o / Chinese
o / Traveller
o / Gypsy
o / Any Other
o
Can we contact you in English:
Yes oNo o
Office Use: If not English please note on progress notes / If no, what language to use: / Verbally:
Written:
Special Requirements: Braille oLarge Print oTape oType - Secondary oJoint o
Disability / Hearing Impairment
o / Visual Impairment
o / Restricted Mobility
o / Wheelchair used out of home
o / Wheelchair used in and out of home
o / Other Disability
o
If other disability please give brief details
Preferred Method of Contact / Any o / Letter o / Email o / Telephone o
Economic Status / Employment
o / Full Time
> 30 Hours
o / Part time
<30 Hours
o
Govtl/New Deal
o / Retired
o / Full time student
o / Reg Unemployed/Job Seeker
o
Not seeking work/at home
o / Long term sick/disabled
o / Child under 16
o / Other
o

Issued January 2008

Reviewed July 2015 2 of 16