Supported Accommodation Referral Form

SUPPORTED ACCOMMODATION REFERRAL FORM

Please complete this form if you need Accommodation with Support.

Date of referral:
Are you referring yourself or someone else?
Referrer Details: / Name
Email
Telephone
Organisation of Referrer
If referring on behalf of someone else, is the person aware of the referral?
Who should we contact if we require further information to support this referral?
Is this an emergency referral
Eg currently in emergency accom or other exceptional circumstances. / Please give details

PERSONAL INFORMATION:

Name:
Date of birth:
Current address:
Correspondence Address if different from above:
Telephone number:
Email:
Preferred method of contact?
Who should we phone if we are not able to contact you?
Do you have any communication needs?
Employment status:
Child Details incl age / Will child reside with you

ACCOMMODATION:

What is your current living situation?
Are there any problems with your current accommodation? (rent arrears, issues with neighbours, being evicted)
Where was your last permanent accommodation & why did you leave?
Have you ever lived independently including supported housing?
Why do you need supported housing?

TYPE OF SUPPORT REQUIRED:

Do you have support needs relating to your tenancy or accommodation?
Do you have support needs around managing money?
Do you have support needs relating to finding or maintaining work and accessing and engaging positively with the community?
Do you have any support needs relating to your health and wellbeing?
Are any of these support needs urgent/immediate? If so which ones and in what way?
What type of supported housing are you interested in? / Mental Health
Young People
Drugs & Alcohol
Learning Difficulties
Young Parents

SPECIFIC SUPPORT NEEDS

Do you consider yourself to have mental health support needs?
If yes, do you have a diagnosis and what is this?
How does your mental health affect you?
Do you consider yourself to have learning difficulties?
If yes, do you have a diagnosis and what is this?
How does your learning difficulty affect you?

RISKS:

We lone work, often with very vulnerable people. Therefore thinking about your safety and ours, please consider the following;
Are there any risks or behaviours that you feel we need to know about in relation to your request. E.g.you’ve hurt someone, have damaged any property or belongings intentionally, have intentionally caused a fire, have been in trouble with the police, have had a problem with legal or illegal drugs or alcohol, have you ever tried to take your own life, have you ever intentionally harmed yourself
It is important that you are honest about this as it may affectyour application if you fail to disclose anything.
Do you have any criminal convictions including Arson?
If yes please give details
Do you feel at risk from other people? If so please provide details
Do workers need to know anything about you before entering your home? If so, please provide details:
Answering yes does not mean that you won’t be able to receive a service but makes sure that the most suitable help can be found.

ABOUT YOU:

In order to refer you to the most appropriate provider, we need to know some more information about you.
Which of these describes you? (Please list all that are relevant):

Homeless family with support needs
An offender or at risk of offending
Older person with dementia and/or mental health problems
Older person with support needs
At risk of domestic violence
Person with a physical or sensory disability
Person with alcohol misuse problems Person with drug misuse problems Person with HIV/AIDS
Person with a learning disability
Person with mental health problems
A refugee
A rough sleeper
Single person homeless with support needs
A teenage parent
A gypsy or travellers with support needs,
A young person at risk
A young person leaving care

Of the above, which would you say is your main need?
Are you receiving services from any of the following (please list all that are relevant) Please provide contact details.
GP Service
Specialist Medical Consultant
Services related to Physical Health Domiciliary Care Service
Occupational Therapist, Social Worker Care Manager
Community Psychiatric Nurse
Psychiatrist
Addiction Recovery Services
Counsellor Therapist Mental Health Counsellor Therapist Generic Community Mental Health Team Probation Officer
Youth Offending Team Officer Children’s Services After Care Worker Floating Support Service, Other service)
Child and Adolescent Mental Health Service (CAMHS)
Other

REFERENCES:

Some Providers require one or more references before offering a service. This can be an advocate, family member, friend or someone who works for one of the agencies listed above, who is currently supporting you.

Reference 1:
Name:
Address:
Organisation
Telephone Number:
Email:
Reference 2
Name:
Address:
Organisation
Telephone Number:
Email:

CONSENT
In printing your name below you are consenting to this referral form being sent to Alliance Homes for triage.

Name:

North Somerset Council may pass relevant information about you to external organisations in order to arrange support to meet your health and social care needs. Please note all organisations we pass your information to will have an agreement with us to ensure they meet the standards of the Data Protection Act,

The information on this form will only be shared with Alliance Homes and the appropriate Provider to receive the referral. Any information we ask you to provide is purely to enable the Provider to assess whether they can offer you a service.

PLEASE NOW EMAIL THIS FORM TO: .