Referral Form Referral Agency Details Declaration I agree that the information contained in this referral / initial assessment form is true and accurate and I consent to it being used as part of the assessment process.By Signing below, I agree that all information provided is true and accurate. I also understand that Goddess Living Supported Housing has the right to close my housing application should I provide any information which is incorrect or false. Should it be discovered that I have secured a tenancy with false information, I may be liable to be served with a Section 8 notice. I agree to the above declaration I do not agree to the above declaration Information Sharing I understand that Goddess Living Supported Housing may carry out additional checks on the information I have provided by contacting other agencies (for example : mental health services/probation officer/police services) . Please state if you give permission for information to be shared with relevant agencies to inform accurate assessment of housing needs and risk. I consent to information sharing I do not consent to information sharing Referral Agency Name of person making referral Referral Agency contact number Reason for referral Areas required for accommodation Date of Referral Applicant Details Applicant Name Including title Date of Birth Place of Birth National insurance number Gender Contact details Current Address Ethnic origin of applicant Does the applicant follow a religion? Does the applicant have any communication needs? Large Print Braille Translator Easy Read Pictures/Symbols BSL Other Please provide details Please provide details : Financial information What benefits do you currently receive? How often are your benefits paid? Total amount received Do you receive PiP? If yes, what rate of PiP do you receive? Offending History Please note – Declaration of criminal offence(s) does not necessarily mean that you will be excluded from applying for accommodation with Goddess Living Supported Housing . Have you ever been convicted of a criminal offence? (including spent offences) Or do you have any pending court appearances or subject to bail conditions? Yes No Nature of offence Date Probation officer name Probation officer contact number Probation officer email Probation office Housing History 3 years housing history required Address Dates Tenure Landlord Details Reason for leaving Medical information Is the applicant allocated a Social Worker? Yes No Is the applicant registered with a GP?If yes provide details: Yes No Has the applicant ever been sectioned/detained under the mental health act or subject to a community treatment order? Yes No Mental health history (including any diagnosis) Does the applicant receive any support regarding their mental health? CPN, CMHT Yes No Does the applicant have any learning difficulties? Yes No Physical health history Ground floor room required? Yes No Applicants present medication or treatment : Details of Care Plan Approach: Substance misuse Does the applicant currently use drugs? Please include details on regularity of use, administration ect. Yes No Does the applicant have a drugs worker? Yes No If no, is the applicant open to engaging with drug use support? Yes No Not Required Does the applicant currently drink Alcohol? Please include details of regularity Yes No How often? Does the applicant receive any support around alcohol use? Yes No Not Required Does the applicant receive any support around alcohol use? If no, is the applicant open to support to address alcohol use? Yes No Not Required Support Needs Reasons for requiring supported accommodation At risk of becoming homeless/ evicted within the next 28 days Ability to manage mental health On going issues with drug misuse On going issues with alcohol misuse Ability to engage with Mental health services On going issues with alcohol misuse Medication prompts Attending appointments Appointment reminders Accessing drug and alcohol services Medication ordering/collection Access to GP/ Health services Ability to manage physical health Improved quality of life Building healthy support networks Ability to manage personal hygiene Developing Independent living skills Risk of domestic abuse (victim) Risk of Domestic abuse (perpetrator) Reduce social isolation Involvement in community activities Obtaining training / education opportunities Obtaining volunteering opportunities Obtaining employment Financial support required – Budgeting Risk of offending Risk of harm for others Risk of self harm / suicide attempts Reduced feelings of isolation Ability to keep home safe and secure Developing problem solving skills Developing interpersonal skills Increased confidence Other identified support needs Risk Assessment Please provide information below (or send a current risk assessment)Risk Guidance : Low risk – No evidence of behaviours related to risk. Medium Risk – Evidence of behaviours linked to risk but is engaging with support to address this. High Risk – Regular engagement with behaviours linked to risk and is not engaging with support to address this. Does the applicant have history of the following risks? Is this risk assessment a self assessment ? Is this risk assessment a professional assessment? Violent or aggressive behaviour Indicate Risk level L Indicate Risk level M Indicate Risk level H Self-Harm / Suicide attempts Indicate Risk level L Indicate Risk level M Indicate Risk level H Mental health Indicate Risk level L Indicate Risk level M Indicate Risk level H Drug/ Alcohol misuse Indicate Risk level L Indicate Risk level M Indicate Risk level H Medication: Non-compliance with prescribed medication Indicate Risk level L Indicate Risk level M Indicate Risk level H Child protection issues? Schedule one offences? Indicate Risk level L Indicate Risk level M Indicate Risk level H Sexual offending? Please include details of who the risk is posed to (e.g Adult male/female/children) Indicate Risk level L Indicate Risk level M Indicate Risk level H Any other criminal offences/ Convictions? Include risk to Staff/ Tenants/ General public Indicate Risk level L Indicate Risk level M Indicate Risk level H Risk of self neglect / Self Care Indicate Risk level L Indicate Risk level M Indicate Risk level H Anti Social behaviour Indicate Risk level L Indicate Risk level M Indicate Risk level H Damage to property Indicate Risk level L Indicate Risk level M Indicate Risk level H Arson/ Firearms offences Indicate Risk level L Indicate Risk level M Indicate Risk level H Rent arrears / Managing finances Indicate Risk level L Indicate Risk level M Indicate Risk level H harm Indicate Risk level L Indicate Risk level M Indicate Risk level H Should any additional precautions be taken into account when interviewing the applicant? Indicate Risk level L Indicate Risk level M Indicate Risk level H Have additional checks been completed? Yes No Send
