Flagship is committed to equality of opportunity. All efforts will be made to prevent discrimination or other unfair treatment against users of its services, regardless of race, colour, nationality, religion, disability, gender, age, sexual orientation and medical status.

Accommodation & support Floating support Triage Pre-tenancy Crisis intervention Date of Referral: Only available if previously

supported byFLAGSHIP

Title / First Name / Surname / Date of Birth
Address:
Postcode: / Contact Telephone No:
Gender MF / Pregnant? Yes No / National Insurance No.
What is the best way to contact
them? If we can’t contact them, is there anyone else who we can speak to?

Next of Kin – for emergencies only

Name:
Relationship: / Contact No.
Always lived in Leeds? Yes No / Returning to Leeds? Yes No N / A
If No, since when? / If Yes, from where?
Housing Register Number (if applicable) / Priority Status
(if applicable)
Preferred Area
(ENE, WNW, AireValley) / Care Leaver
(yes / no)

Please tick one

Renting from council or housing association / Renting from a private landlord
Lodger / Living in a caravan or barge
Own the home they/you live in / In prison Release date:
Living with friends or family / Living in a bail hostel or approved premises
Sofa Surfing / Hospital
Rough Sleeping / Children’s home/foster care
Sheltered Housing/Care home / Supporting housing/foyer
Temp council accommodation / Refuge
Bed and breakfast / Other Please state
Has the person been refused accommodation in the last year? If so give details:
Please list any tenancy-related warnings, notices or evictions:
If this referral is for the person and a child (or somebody else who is cared for by the person) please add their details below:
Name / Age / M/F / Relationship / Lives with applicant
Yes/No
Yes/No
Yes/No

Please tick the areas on this assessment that you/they need support with.

Maximising income/benefits / Employment
Reducing debts / Amount of arrears, if any:
Education and training / Social and cultural inclusion
Voluntary work / Family and friendships
Physical Health/Harm / Mental wellbeing
Alcohol/Drug use / Accommodation & living skills
Offending behaviour and orders / Avoiding Harm or Harming others
Confidence/involvement/control / Children/Parenting skills
Other / Please state:
Please provide a summary of the issues you have ticked, starting with the most urgent.
Has the person recently been involved or is currently involved with any other services/agencies? Please provide details:

Please list the most recent and serious offences (if applicable)

Offence/charge / Details / Date / Outcome/sentence/supervision

Please tick if it applies to the persons /your offending history

Risk Tier Violent offence Race-related offence Sex offence

Fire setting/Arson MAPPA status MARAC PPO IOM Risk to staff

Risk to others Avoid harm

Additional risk & vulnerability-related information. Including risk to the person and risk within the home
First Name: / Surname: / Phone:
Organisation: / E-mail and postal address:
How long have you known the person for?
Would you like to be invited to the assessment? / Yes / No
Will the person require translation at the assessment?
If English is not the persons’ first language what is it? / Yes / No
Is the person aware of this referral and in agreement with it? / Yes / No

Completed referrals forms can be

Posted; FAO FLAGSHIP, Tennant Hall, Blenheim Grove, Leeds, LS2 9ET (Recorded Delivery advised)

Emailed;

Faxed; FAO FLAGSHIP, 0113 3030221

If you require further assistance regarding this referral please contact 0113 2000852

INTERNAL USE ONLY

Date Referral Received:

Flagship treats everyone fairly, with respect and without prejudice. Diverse means different. We are all different, therefore diversity includes us all.

People requesting support will not be refused on the grounds of gender, ethnic origin, colour, religion, sexuality, disability, appearance or health.To ensure that this policy is effective, we monitor our referrals according to the categories below.

Completion of this form is voluntary, but it does help us provide a better service if this information is given.

Thank you.

I WOULD DESCRIBE MY ETHNIC ORIGIN AS :
White – British Irish Other
Black or Black British - Caribbean African Other
Mixed – White & black Caribbean White & black African White & Asian Other

Asian or Asian British – Indian Pakistani Bangladeshi Other

Chinese Other I do not wish to answer
I WOULD DESCRIBE MY SELF AS:
Not DisabledDisabledWheelchair User I do not wish to answer
If disabled please state nature of disability
Hearing Physical Visual Learning Mobility Other
I WOULD DESCRIBE MY SEXUALITY AS:

Heterosexual Bisexual Gay Lesbian I do not wish to answer

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