In order for your referral to be processed, please:-
Ensure you complete all sections of the referral form(incomplete forms will be returned)
Enclose an up-to-date risk assessment(excluding self referrals)
Gain client consent for the referral to be made
KEY CRITERIA FOR REFERRAL(for full criteria please request a referrers guide)
Providing: single, temporary (6 month), self contained, supported tenancies in Leeds
Applicants should have housing and mental health support needs
Applicants to fully engage and co-operate with the aims of the service
Applicants must possess sufficient daily living skills to enable them to maintain an independent tenancy with the level of support we are able to provide.
Applicants should generally be resident in, or have a local connection with Leeds to enable them to access accommodation via the Choice Based Lettings Scheme operated by Housing Options.
Our Housing Support Workers generally work alone; consequently the behavior and history of applicants should not be such that they could constitute a significant risk to themselves or others in the living and support environment provided.
Applicants who have alcohol, drug or other substance use issues should not have a problem that is so severe that it is likely to undermine their ability to maintain a supported tenancy
Applicants should understand the purpose and temporary nature of the scheme and be willing to accept the responsibilities and obligations involved in living in supported housing.
Eligible for Housing Benefit or access to personal/public funds required to ensure all utilities, food, rent and council tax etc can be paid for.
- In line with the “Right to Rent” legislation (February 2016). Applicants must show 2 forms of ID at assessment or on sign up (passport, driving license, benefit letters, bank statement) NB copies will need to be taken and held of file.
Title: Mr / Mrs / Miss / Ms / Date of Birth:
Last name: / National Insurance Number:
First name(s): / NHS Number:
Current Address / Care of Address
Postcode:
Telephone Numbers:
Land line:
Mobile: / How should we contact you / this client?
By telephone
By post
Through the referrer
By e-mail ______
Other Please state:______
2. CARERS DETAILS / 3. NEXT OF KIN / EMERGENCY CONTACT
Name (if applicable) / Name
Relationship: / Relationship:
Contact Number: / Contact Number:
Address: / Address:
Has the client given consent for the carer to be involved in this referral?
YES NO N/A / Has the client given consent for the next of kin to be involved in this referral?
YES NO
4. REFERRER
Title: Mr / Mrs / Miss / Ms / Dr etc… / Date referral form completed:
Last name: / Job Title:
First name(s): / Organisation:
Address: / Contact details:
Landline:
Mobile:
E-Mail :
Has the client given consent for this referral to be made? YES NO
If no please explain:-
How long have you known this client? / In what capacity do you know this client?
5. SOCIAL NETWORKS AND RELATIONSHIPS
Are there any other adults looking to be re-housed with the applicant? Yes No
If yes, who? ______
Are there any children looking to be re-housed with the applicant? Yes No
If yes, how many? ______Ages of the children ______
Other Agencies
Involved / Name/Address / Contact
Number / Level of contact
Psychiatrist
C.P.N
Care Co-Ordinator
Social Worker
G.P.
Day Care Services
Probation Officer
Drug/Alcohol Services
Other
Other
6. EMOTIONAL AND MENTAL HEALTH
Mental Health Diagnosis and / or a description of symptoms if undiagnosed:
Is the client on any prescribed Medication? Yes No
Please give brief details if ‘yes’
Does the client take their medication as prescribed? Yes No
7. HOUSING / ACCOMMODATION
Last 5 years of addresses / From / To / Type of accommodation / Reason for leaving
1.
2.
3.
4.
5.
6.
Is the client registered with Leeds Homes?
Yes No / If yes, what is their bidding number? / If no, are there any reasons why they would not be able to?
Has the client got any previous rent arrears?
Yes how much is owed? £______
No
If yes, has payment plan been arranged?
Details ______/ Has the client:-
Ever been evicted? Yes No
Had any issues regarding
Anti Social Behaviour Yes No
Does the client have any pets that they intend to move with them?
Yes No Please note no pets are allowed in any of our flats.
8. OFFENDING & RISK INFORMATION
These are the areas we have flats.
Please tick any areas that you/client cannot live and the reasons why. / Harehills (6)
Chapeltown (11)
Chapel Allerton (1)
Hunslet (1)
Beeston (2)
Meanwood (1)
Hyde Park (2)
Woodhouse (2)
Please tick all areas of risk that apply / Self Harm / Substance abuse
A current risk assessment is required. / Self Neglect / Arson
Violence to property / Violence to providers
Violence to carers / Violence to others
Unable to budget / Vulnerable
Non-Engagement with services
Other: Please specify
Please provide any additional details of risk that may be relevant to this referral.
i.e. male/females workers only. No lone working. Office contact only etc
9. DRUG AND ALCOHOL
Does, or has, the client ever used drugs, solvents or alcohol? YES NO
If ‘yes’ please answer the following questions:
- Is this a current issue? YES NO
- Is the client currently accessing any drug or alcohol services? YES NO
- What substance(s) did/does the client use?
- Is the client diagnosed as having a drugs or alcohol addiction? YES NO
- Doesthe client consider him/herself to have an addiction? YES NO
- Is the Alcohol and/or drug use deemed to be Managed Chaotic
10. PHYSICAL HEALTH
Does the client have any physical or general health issues?
Are there any additional housing needs to be considered?
i.e. needs wheelchair access, can’t climb more than 5 stairs, needs walk in shower, needs bath?
No Yes
If yes, please outline.
Is the client pregnant? Yes No . If yes, when is the baby due? ______
11. FINANCES(required to assess suitability)
Is the client in receipt of benefits? YES NO
Income / How much / How oftenHousing Benefit / Weekly Fortnightly Monthly
ESA / Weekly Fortnightly Monthly
JSA / Weekly Fortnightly Monthly
Income Support / Weekly Fortnightly Monthly
Child Tax Credit / Weekly Fortnightly Monthly
Working Tax Credit / Weekly Fortnightly Monthly
DLA / PIP / Weekly Fortnightly Monthly
Pension Credit / Weekly Fortnightly Monthly
Any Savings?
12. EMPLOYMENT
Please tick as applicable / Employed / Unemployed / Long Term Sick
Student / Retired / Other (specify):
13. ADDITIONAL SUPPORT NEEDS
Please outline the areas in which the client may require support?
Areai.e. debt, volunteering, work, MARAC, Safeguarding, etc / Outline of support required
14. OTHER
We will do out best to accommodate the following, but it will be dependent on available HSWs
Does the client need to be supported by a gender specific support worker?
Male worker Female worker Either
Does the client need to be supported by a worker of a specific cultural background?
No Yes If yes, please specify:______
Does the client require and language specific worker or interpreter?
No Yes If yes, please specify:______
Any additional details to support this referral?
Equal Opportunities
Touchstone strongly believes that particular groups of potential and actual service users are at risk of finding services inaccessible, or of experiencing ongoing poor mental health and poor quality of life, such as people from Black or Minority Ethnic communities, Women, Gay men, Lesbians and Disabled people. Because of this, we need to make sure that we are an accessible service and to do this we must monitor the referrals that we receive to make sure that we are reaching all sections of society.
This page is designed to be detached from the rest of the form upon receipt. The information is anonymised; it will be stored separately from client files and used for monitoring and statistical reasons only.
How do you identify yourself (gender):(Please circle)
Male
/Female
Do you live and work in the gender assigned at birth? (Please circle)
Yes
/No
/Did not want to state
How do you identify yourself (sexuality):(Please circle)
Lesbian / Gay / HeterosexualOther / Bisexual / Did not want to state
What is your cultural background: (Please circle)
Does not want to state
White / Dual / Asian or British Asian / Black or Black British / Other Ethnic GroupBritish / White and Asian / Indian / Caribbean / Chinese
Irish / White and Black African / Pakistani / African / Gypsy/Traveller
Other / White and Black Caribbean / Bangladeshi / Other / Other
Other / Kashmiri
Other
Do you have a physical health problem that affects your life on a day to day basis, or consider yourself physically disabled? (Please circle)
Yes / NoDo you have a religion: (Please circle)
Christian / Buddhist / None
Hindu / Muslim / Other
Sikh / Jewish / Did not want to state
What is your relationship status: (Please circle)
Married / Co-habiting / Other
Civil Partnership / Single / Did not want to state
What is your residency status: (Please circle)
British Citizen / EU National / Refugee / Other
Asylum Seeker / Foreign Student / Destitute / Did not want to state
CONSENT FORM /
To:
AUTHORITY TO DISCLOSE INFORMATIONI confirm that I am currently applying to receive or are receiving housing support from Touchstone.
I hereby give my consent for Touchstone Housing Support Service to gather information about me and my support needs from other agencies and relevant people who know me.
First name:Last name:
Address:
Signature: ______(handwritten signature required)
Date : ______
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