HOME WORKS REFERRAL FORM

DATA PROCESSING STATEMENT
Any personal information you share with Southdown Housing Association will be kept secure and used in line with the General Data Protection Regulation (GDPR). It will only be looked at and used to help make sure we give you an effective service.
Some information may be shared with other support agencies to help you access further services and make sure the services you get are right for you. We can share your information without your permission if we are concerned about your safety or the safety of others, or where we are required to by law.
You can withdraw or change your agreement for Southdown to hold or process your personal information at any time.You can also ask to see the information Southdown holds about you.
More information about how Southdown stores and uses your data is available on our website we can send you a leaflet if you would prefer.
Please email the completed form to
Consent(please note that we are unable to approach clients without their consent)
Has this statement been read to, and acknowledged by the client? / Yes ☐ No ☐
Has the client explicitly consented to this referral being made to Home Works? / Yes ☐ No☐
Client details
Title: / First name: / Last name:
Date of Birth: Please note Home Works can only support clients aged 16 to 64 years
Address: / Landline:
Mobile:
Postcode: / Email:
Is client open to ASC? Yes ☐ No ☐
Don’tKnow ☐ / If yes:Adult Social Care Reference Number:
E-mail address of ASC case worker:
Please list all other members that live as part of the household: / Is the client a carer?
Yes ☐ No ☐
Are there any communication needs? i.e. hearing/sensory impairment, English not first language
Comments:
Nationality: / National Insurance number:
Care leaver? Yes ☐No ☐ Don’t know ☐ / NHS Number:
Referrer Contact Details
Name: / Landline:
Name of Agency / organization: / Mobile number:
Your role:
Address: / Email address:
Date of Referral:
Please complete the following questions – there must be a housing need and at least one vulnerability listed in order to meet Home Works criteria. If these fields are not completed they will be returned.
What is the clients need for support? (Please tick all that apply)
1)No Accommodation / ☐
2)Losing or at risk of losing accommodation / ☐
2.1) End of tenancy / tied accommodation (non-fault) / ☐
2.2) Relationship breakdown / ☐
2.3) Bereavement / ☐
2.4) Housing related debts / ☐
2.5) Tenancy breach including anti-social behaviour / ☐
2.6) Fleeing violence / harassment / safeguarding issues / ☐
3)Unsuitable housing / ☐
3.1) Inappropriate housing due to disability / ☐
3.2) Serious disrepair / ☐
3.3) Overcrowding / ☐
3.4) Under Occupation / ☐
4)Resettlement support – e.g moving into a new home and needing support & guidance to set this up / ☐
Current housing situation: i.e. Private rental, Local Authority (Council), Housing Association, Temporary accommodation, Street Homeless, Sofa Surfing, etc.
Comments:
Please explain the need for support in further detail: i.e. what has led to the current need for support, what support is required, what is the desired outcome, etc.
Comments:
What has already been tried & what was the outcome? i.e. specialist agency appointment, ASC referral etc.
Comments:
If placed in Temporary accommodation, please state which authority has placed the client there:
Please state whether there are engagement issues. If so, please tell us the most effective way to engage the client:
Yes ☐No ☐ Don’t know ☐Comments:
Please describe how their vulnerability impacts on their housing i.e long term health condition, substance misuse and other relevant information.
Comments:
What formal and informal networks does the client have?i.e O.T, key worker, relative, STEPS, (Navigator), friends etc.
Comments:
Initial Safety Information– if YES, please expand below:
everyone released from prison is on licence for at least 12 months / Yes / No / Don’t Know
Environmental issues e.g. pets at the property, smoking, sharps, property in disrepair
Comments: / ☐ / ☐ / ☐ /
Risks to others e.g.subject of abuse, safeguarding, domestic abuse, ASB
Comments: / ☐ / ☐ / ☐ /
Risks from others e.g.subject of abuse, safeguarding, domestic abuse, ASB
Comments: / ☐ / ☐ / ☐ /
Risks to themselves e.g. self-harm, suicidal, self-neglect
Comments: / ☐ / ☐ / ☐ /
Do you recommend any specific visiting arrangements, i.e. male/female/joint visits/ community only?
Comments: / ☐ / ☐ / ☐ /
Allocateda probation worker with CRC (Community Rehabilitation Company)
Comments: / ☐ / ☐ / ☐ /
Allocateda probation worker with NPS (National Probation Service)
Comments: / ☐ / ☐ / ☐ /
Is this a self-referral? Yes ☐No ☐ If yes, where heard of service?:

All further sections are for Home Works office use only

Equality and Diversity
Ethnic Origin:
White British / ☐ / Asian / Asian British Indian / ☐ /
White Irish / ☐ / Asian / Asian British Pakistani / ☐ /
White Other / ☐ / Asian / Asian British Bangladeshi / ☐ /
Mixed White and Black Caribbean / ☐ / Asian / Asian British Other / ☐ /
Mixed White and Black African / ☐ / Black / Black British Caribbean / ☐ /
Mixed White and Asian / ☐ / Black / Black British African / ☐ /
Mixed & Other / ☐ / Black / Black British Other / ☐ /
Gypsy / ☐ / Chinese / Other ethnic group: Chinese / ☐ /
Romany / ☐ / Chinese / Other ethnic group: Other / ☐ /
Irish Traveller / ☐ / Gypsy / Romany / Irish Traveller: / ☐ /
Do not wish to disclose / ☐ / Arab / ☐ /
Faith & Cultural needs:
Buddhist / ☐ / Christian (all denominations) / ☐ /
Hindu / ☐ / Jewish / ☐ /
Muslim / ☐ / Sikh / ☐ /
None / ☐ / Do not wish to disclose / ☐ /
Any other religion (Please state): / ☐ /
Gender:
Male / ☐ / Female / ☐ / Transgender / ☐ /
Other / ☐ / Does not wish to disclose / ☐ /
Sexuality
Bisexual / ☐ / Gay / ☐ / Heterosexual / ☐ /
Lesbian / ☐ / Does not wish to disclose / ☐ / Other / ☐ /
Would the client consider themselves disabled?
Mental Health / ☐ / Learning Disability / ☐ / Hearing Impairment / ☐ / Other / ☐ /
Visual Impairment / ☐ / Progressive Disability /
Chronic Illness / ☐ / Mobility / ☐ / Do not wish to disclose / ☐ /
Primary Client Group / Secondary Client Group / Select the Client Group that most closely matches the applicant.
Alcohol Misuse Problems / ☐ / Alcohol Misuse Problems / ☐ /
Drug misuse problems / ☐ / Drug misuse problems / ☐ /
Learning disabilities / ☐ / Learning disabilities / ☐ /
Mental Health Problems / ☐ / Mental Health Problems / ☐ /
People at risk of domestic abuse / ☐ / People at risk of domestic abuse / ☐ /
Physical disability / ☐ / Physical disability / ☐ /
Sensory disability / ☐ / Sensory disability / ☐ /
Refugees / asylum seekers / ☐ / Refugees / asylum seekers / ☐ /
Acquired brain injury / ☐ / Acquired brain injury / ☐ /
Unable to speak English / ☐ / Unable to speak English / ☐ /
Long term health condition / ☐ / Long term health condition / ☐ /
Autistic spectrum condition / ☐ / Autistic spectrum condition / ☐ /
Poor Independent living skills / ☐ / Poor Independent living skills / ☐ /
None identified / ☐ /
CCG Checker: Area added to Inform / ☐ /
Gateway Officer - Proceed to:
Proceed to Assessment / ☐ / Explained what will happen next? / Yes ☐No ☐
Proceed to Action Plan / ☐ / Completed by:
Redirection & Close / ☐ / Date:

1

Home Works GB April 2017