Prospective Resident Referral Form

The Burgess Park House offers supported housing accommodationfor those who have been homeless.We encourage residents to take personal responsibility as much as possible and make sustainable changes in their lives. There is also an emphasis on vocational guidance to help people into Work, Study, Training, new career paths and meaningful occupation.
In completing this form, all sections must be fully addressed with as much information as possible- We are looking for a sense of who you/the person is! Please attach any additional information to support the application at the back of the form.
Please contact the team on: 020 7703 9613 for our email/address.
Part 1: Personal Details
Title: Choose a title.
Forename: Click here to enter forename.
Surname: Click here to enter surname.
Date of Birth: Click here to enter date of birth.
Current address and contact details:
Click here to enter current address and contact details
Type of accommodation this is (e.g. Hostel, B&B etc.)
Length of time at this address:
Click here to enter length of time at this address.
Part 2: Referral Agency Details
Name and Address of Agency:
Click here to enter name and address of agency.
Telephone Number: Click here to enter telephone number.
Contact Person (Care Manager, Keyworker etc.): Click here to enter contact person.
Part 3: Rent an Service Charge
The weekly charge for the Burgess Park House is: / £256.87 Per Week
It is likely that all, or most, of the weekly charges will be paid in housing benefit by the local authority
Please state whether prospective client has agreed to pay a weekly contribution towards service charges and towards a rent contribution scheme:
Yes / ☐ / No / ☐ /
The Service Charge is presently £15.00 Heating, Hot water, Cooking Fuel, Laundry and Water Authority Charges and lighting.
Rent Deposit Scheme is £5.00 per week which is returnableat the end of the tenancy, if both parties agree to the amount of deposit returnable, which is dependent on the flat being in a good lettable condition.
Part 4: Key Background Information
a)Social History:
Click here to enter social history.
b)Family History:
Click here to enter family history.
c)Current Housing/Homelessness Situation.
Click here to enter details of homeless history.
d)Previous contact with Homeless services:
Click here to enter details of contact with homeless services.
e)History of Substance use?
Click here to enter details of other drug use.
f)Any Criminal Convictions?
Click here to enter details of previous convictions.
g)Criminal proceedings pending (if any):
Click here to enter details of criminal proceedings pending.
h)Independent Living Skills:
Click here to enter details of previous convictions.
To assist with the assessment, it would be appreciated if the referral agency could obtain/forward copies of any assessments carried out health or social care agency involved in the client’s case.
Part 5: Medical Information
a)Details of Current GP (please provide name, address and telephone number):
Click here to enter current GP details.
To assist with the assessment, it would be appreciated if the referral agency could obtain a copy of the Patient Summary Report from the clients present GP
b)Details of Medical Conditions:
Click here to enter details of medicalconditions.
c)Contact with Primary Health Services and details of Mental Health Issues:
Click here to enter details of mental health issues.
To assist with the assessment, it would be appreciated if the referral agency could obtain copies of the most recent CPA and/or any other report from the Community Mental Health Team that is supporting the client
d)Any Hospital Admissions?
Click here to enter hospital admissions.
e)Any current medication?
Click here to enter list of current medication.
Part 6: Previous Accommodation, Addressesand reasons for moving on (Past 5years to present)
a)Click here to enter address and reason for moving on.
b)Click here to enter address and reason for moving on.
c)Click here to enter address and reason for moving on.
d)Click here to enter address and reason for moving on.
e)Click here to enter address and reason for moving on.
f)Click here to enter address and reason for moving on.
Part 7: Income
a)Is the client presently claiming benefits? / Yes / ☐ / No / ☐ /
b)If YES which office deals with their claim:
Click here to enter address and telephone number.
c)What benefit is the client presently receiving:
Click here to enter name of benefit and amount (specify: week, fortnight or monthly)
d)National Insurance Number: / Click here to enter NI Number. /
Part 8: Life Skills: Descibe any current support or help needed
a)Budgeting:
Click here to enter level of assistance required
b)Mobility:
Click here to enter level of assistance required
c)Daily Living Skills/Personal Hygiene:
Click here to enter level of assistance required
d)Shopping:
Click here to enter level of assistance required
e)Social:
Click here to enter level of assistance required
f)Literacy:
Click here to enter level of assistance required
Part 9: Interest and Daytime Activity
a)Please tell us about, friendships, social, ethnic or cultural networks that are important to the client?What role does faith/spirituality play in their life?
Click here to enter details here.
b)How does the client occupy themselves during an average day:
Click here to enter details here.
Part 10: Ongoing Support
Please give the name, address and telephone of any agencies presently providing support to the client
Agency: / Click here to enter details. / Agency: / Click here to enter details. /
Contact: / Click here to enter contactdetails. / Contact: / Click here to enter contact details. /
Address: / Click here to enter address. / Address: / Click here to enter address. /
Telephone: / Click here to enter telephone. / Telephone: / Click here to enter telephone. /
E-mail: / Click here to enter Email. / E-mail: / Click here to enter Email. /

In the event that the placement at Burgess Park Houseis assessed as being unsuitable, the referring agent will need to take responsibility for finding an alternative place of accommodation.

Part 11: The information provided is a true and accurate record please sign below:
Referring Worker / Click here to enter details. / Client: / Click here to enter details. /
Name: / Click here to enter contactdetails. / Name: / Click here to enter contact details. /
Signature: / Signature:
Date: / Click here to enter a date. / Date: / Click here to enter a date. /

Once fully completed please call the team to for the address/email details 020 7703 9613.

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West London Mission – Burgess Park House 2017