Referral Form Liverpool Housing Support

(Please complete all sections)

Name:
Date: / Referrers Name:
Agency:
Tel’Number:
Current Address:
Tenure/type (e.g. private rented/hostel/housing assoc.):
Date You Moved In:
Telephone Number): / Ethnic Origin:
Sex:
Date of Birth:
NI number:
Sexual Orientation:
Transgender:

Please tell us about your current circumstances by answering the questions below: -

Do you need to move from your current accommodation? YES NO
Please provide information about your current housing circumstances in the space below
Please tell us how you want us to help/ referral reason
Support Issues:(Please indicate all of your support needs)
Income/Benefits / Harassment / Physical Health
Paying Bills / Neighbour Relations / Learning Difficulties
Budgeting / Leisure/Daytime Activities / Offending
Debt / Nuisance Issues / Education
Household Tasks / Social Isolation / Other
Furnishing/Decorating / Employment/Training / Other
Please provide details of these support needs:
Are there any risk issues? YES NO DON’T KNOW
(It is important that we know of any risks to yourself, to our staff who will be working with you, to others or from others. This will help us decide the most appropriate approach to meet your needs)
Alcohol misuse
Drug misuse
Aggression/violence
Harassment to others
Sexual offending
Anti-social behaviour
Suicidal thoughts
Suicide attempts
Self harm
Mental health issues
Victim of domestic abuse
Victim of sexual assault
Victim of harassment
Gambling issue
Home/environment risk
Other

Please note that by signing this document you are in agreement with the following statement:

Agency Referrals

(Signed on behalf of referring agency)

Name:

Signature:

Date:

“I can confirm that the information given within this referral is, to the best of my knowledge, true and accurate.”

Signed by Client:

Date:

Please return the form to:

Central Area and/or where Resettlement is required / The Whitechapel Centre, Langsdale Street, Liverpool, L3 8DU;
Fax: 0151 2074093; email
Refer/apply online at
North Area / Creative Support, Liverpool Links 181-185 London Road L3 8JG;
Fax:0151 207 1740;
Refer/apply online at Follow the link for referrals and select Liverpool Floating support services
South Area / Riverside, Homeless Prevention and Dispersed Tenancy Service, The Powerhouse, 300 Upper Parliament Street, Liverpool, L8 7JU;
email

CONSENT TO DISCLOSURE AND USE OF INFORMATION

I give my consent for the information that I have given to be shared with services within the LiverpoolMainStayHousing and Support Gateway.* This may include information regarding my stay in my current accommodation.

If applying for further accommodation within MainStay I agree to the Liverpool MainStayHousing and Support Gateway contacting relevant agencies to request additional information that will enable them to process my application for accommodation and assist them in providing support services to myself. I understand that the purpose of this is to identify potential risks and to identify any support needs that I may have and that some of this information may be of a sensitive nature. I also understand that this information may be shared with services within the Liverpool MainStayHousing and Support Gateway.

I understand that some of the agencies contacted to provide information may include but will not be restricted to:

  • Benefits/Income (E.g. Council Tax, Housing Benefit, Benefit Agency)
  • Housing (E.g. Housing Associations, Hostels, Previous Accommodation Providers)
  • Legal (E.g. Solicitors)
  • Education/Training (E.g. Schools, Colleges, Training Providers and Connexions)
  • Health (E.g. GP, Mental Health Services, hospital)
  • Statutory Agencies (E.g. Social Services, Police, YOT, Probation, Prison Service, Home Office, NASS,)
  • Drugs and Alcohol Services (E.g. Detox units, rehabilitation units, Drug Workers)
  • Homeless Organisations
  • Family Members and Friends
  • Other specified persons and Agencies (please state)______

I understand the terms outlined above and agree to the storage and sharing of the information specified above. I understand that all information provided will be processed, stored and treated confidentially in accordance with Data Protection Legislation.

Service User Consent Signature: Date:______

Service User Name: DOB ______

______

* A list of the services within the Liverpool MainStay Housing and Support Gateway is available upon request

Please note if a referral is received without this signed consent then this may delay to processing of the referral while consent is sought. If you are not comfortable with your data being recorded on Mainstay please contact us

1