Resilience Service Self Referral Form

Resilience Service Self Referral Form

Your Name :
Your Address :
Telephone Number: / Email Address:
District Council Area Where you Live : AVDC / WDC / CDC / SBDC
Date of birth: / Date you are sending this Referral:
Do you speak English? / If you don't speak English:
Which languages do you speak?
Do you know someone who can translate for you? Yes / No
Name of translator :
Telephone Number:
(if you don't know anyone who can translate for you we will try to find someone)
If someone is helping you to complete this form, please give their :
Name: / Telephone Number:
Organisation Name (if any) :
Relationship to You :
How did you hear about Connection SupportResilience Service?

Please ensure that you complete each section so that we can understand your situation. If this form is not fully completed it may be returned to you.

If you need help to complete this form please call us on:

Tel: 01296 484322

If a section does not apply, please write N/A in the space provided.

Details of where to send your completed Referral can be found on the last page of this form.

We will need to talk to you on the phone before we visit you.

When is the best time to contact you on the phone?______

If we cannot get hold of you on the phone number you have given, is there someone else we can talk to who can get a message to you?

Name of Contact:

Their phone number:

Tell us about what help you need:
Please describe the difficulties you are experiencing and what help you need:
Do you think you could be at risk of Homelessness within the next 2 months? / Yes
No
Do you have any rent or mortgage arrears?
Delete the ones that don’t apply to you. / Yes: more than one months worth of rent or mortgage arrears
Yes: Less than one month’s worth of rent or mortgage arrears
No rent arrears

Do you have any temporary physical health problems, mental health issues or long term disabilities? Yes / No

If you would like to give us more information about your health, please write here:

Personal History
Please provide FULL information
Have you ever slept rough? Yes ☐ No ☐
If Yes:
How many nights have you slept rough in the past year?
What age were you when you first slept rough?
Have you ever been homeless before? Yes ☐ No ☐
If Yes:
When were you first homeless:
Within the last 3 months ☐
Within the past 12 months ☐
More that 12 months ago ☐
What age were you first homeless?
Have you been in prison in the past year? Yes ☐ No ☐
If Yes:
Date left prison: ______
Were you homeless prior to going into prison? Yes ☐ No ☐
Did you receive resettlement advice in prison? Yes ☐ No ☐
Personal History Summary
This information is required to allow support staff to prepare for the assessment interview with you. Do you have any history of the following? Put an X in the box of the answers that apply to you .
Yes / No / Yes / No
Aggression – towards other people either verbal or physical / Self Harm
Arson / Sex Offences
Domestic Abuse – either by you or to you / Do you have pets living in your home?
What sort of pets?
Substance / Alcohol use / Other (please specify)

Are there any reasons why it may not be safe to visit you at home?

If Yes or Sometimes: please give more details about why or when it might not be safe to visit you.

Are there any other safety issues that you want to warn us about?

We will contact you if we intend to visit you. If it's unsafe to visit you at home, we will arrange to meet you somewhere else.

Monitoring our Service

We want to provide a service, which is fair and available to everyone. To help us monitor this, please answer the following questions:

Gender: Male  Female  Transgender 

Do you consider yourself to have a disability? Yes  No 

Are you an Armed Forces Veteran? Yes  No 

Your Ethnic Origin: (Tick)

A – White / British
Irish
Gypsy, Romany, Irish Traveller
Other
B – Mixed / White & Black Caribbean
White & Black African
White & Asian
Other
C – Asian or Asian British / Indian
Pakistani
Bangladeshi
Chinese
Other
D – Black or Black British / Caribbean
African
Other
E- Other Ethnic group / Arab
Other
F - Refused / Refused / Not Given

The Resilience Service is funded through the Department for Communities and Local Government (DCLG), working closely with the four District Councils in Bucks, Buckinghamshire County Council and other agencies, to provide early intervention homelessness prevention support and advice.

This section of the Referral Form explains how we will use any personal and sensitive personal information that we collect about you as part of the service we will provide to support you.

What information do we collect about you?

The information contained in this Referral Form is the basis of the data we will hold and more details will be required if your referral is accepted for the service.

How will we use the information about you?

Your Referral Form will be handled by our allocation team and passed to the appropriate worker within Connections Support who will contact you to arrange an assessment.

If your support needs fit our criteria for assistance with homelessness prevention, you will be accepted as a client of the Resilience Service, and additional information will be collected.

As the Resilience Service is funded by DCLG, we will need to share data about our service users with them. The information that is shared with DCLG will be anonymised (i.e. it will not include your name).

To support your progress in resolving the issues that put you at risk of homelessness, it may be necessary to share your information with your local District Council and other relevant support agencies. These may include Citizens Advice, mental health services, debt advice, addiction services, family resilience service, education or social care, depending on your situation.

Access to your information and correction

You have the right to request a copy of the information that we hold about you. If you would like a copy of some or all of your information, please email the Admin Manager at: or write to us at Connection Support Resilience Service, Claydon House, 1 Edison Road, Aylesbury, Bucks, HP19 8TE

We want to make sure that your information is accurate and up to date. You may ask us to correct or remove information that is inaccurate.

Confidentiality

The information you provide to us will be stored securely and will comply with data protection regulations.

In signing this form you are giving your consent for us to use your information as detailed above. However, there are two circumstances where we may need to disclose information to others, even if you haven’t given consent:

1)If you tell us that you or someone else is at serious risk of harm

2)You tell us about criminal activities that you are involved in – including benefit fraud.

Signature of applicant: / Date:

If you have any further questions about the way we use your information please phone or email our office.

Thank you for taking the time to complete this form. Please return it by post or email to:

Resilience Service
Claydon House
1 Edison Road
Aylesbury
Bucks, HP19 8TE
Tel:01296 484322 e-mail

Please type: 'Referral' on the Subject Line if sending by email.

What happens when we get your referral?

When we receive the form it will be given to our allocations team for a decision to be made on how we can help you. We will normally contact you by phone within a few days.

We may need to come out to visit you in order to get more detailed information on how we can help you.

If we need to visit you we will ring you to make an appointment, so please make sure that you have given us telephone numbers where we can contact you.

If we cannot contact you by phone, we will send you a letter offering an appointment. We will ask you to ring us to confirm the appointment. If you don't confirm the appointment, your appointment may be cancelled.

If we are not the best people to help you we will tell you if there is somewhere else where you can go for further help.

If you want to know the progress of your referral, please ring 01296 484322. The office is normally open between 9.00 - 5.00 pm Monday to Friday.

Resilience Self Referral revNov 2017 1