Refferal Form – Goddess Living Supported Housing Limited

Referral Form

Referral

Referred by

Date of referral

Telephone

Organisation

Relationship

Service User Details

Name

D.O.B

Address

Postcode

Tel Landline

Tel Mobile

GP Name and Contact Details

National Insurance Number

Next Of Kin Name

Next Of Kin Telephone Number

External Agency Contact Information

Our multi-agency approach enables us to confirm that any individual offered Goddess Living supported accommodation is correct and appropriate for them. Please can you name any other agencies that is involved with the individual.

Probation Officer Involved:

Probation Officer Contact:

Probation Officer Telephone:

Probation Officer email:

CPN Involved:

CPN Contact:

CPN Telephone:

CPN Email:

Other External Agency Involved:

Other External Agency Contact:

Other External Agency Telephone:

Other External Agency email:

Does the individual have capacity to commit to a license to occupy or legal agreement?

Yes No

If No please give detail of the individuals representative below

Name

Address

Telephone

Position

Company Info

THIS MUST BE SIGNED BY PERSON WHO IS BEING REFFERED OR AN EMAIL ATTCAHED FROM THEM CONFIMING THEY CONSENT TO THE BELOW

Declaration

‘I give my permission for enquiries to be made based on the information I have provided to establish accommodation suitability and my support needs. I give my permission for Goddess Living CIC to carry out all necessary checks for the purpose of this application which may include safeguarding related enquiries and previous landlords’ references.

I declare that I can legally reside in the UK and I will provide the company with proof of identification upon my successful application.’

Signature

Date

Diagnosis / Mental Health / Physical conditions/ Known Risk Factors/ Current Medication/ Incidents in the last 6 months and other support needs

Please provide as much information as possible. Include any support in place, restrictions, ADL skills, medication, and CPN Level

PLEASE NOTE: OUR PROPERTIES AND SERVICE:

• DOES NOT HAVE STAFF ON SITE 24/7
• IS NOT SUITABLE FOR INVIDIVUALS WHO REQUIRE STAFF ON SITE 24/7
• IS NOT A SUBSTITUTE FOR PROFESSIONAL MEDICAL OR MENTAL HEALTH TREATMENT

WE HAVE CCTV IN OUR COMMUNAL AREAS, WHICH ARE CHECKED EVERY DAY.

Date of assessment booked:

Notes:

Eligibility Criteria:

• Female aged 18 Plus
• Background information if available e.g. Care Plan, OT Report, etc.
• Service User is prepared to engage with support and engage in other services provided

Making a referral:

Referrer PLEASE NOTE: our properties are not manned on site 24/7 however staff visit our properties at least twice a week to deliver support.

We accept individuals who may be experiencing mental health problems, limited capability for work, No Fixed Abode, Alcohol and substance misuse, at risk of homelessness, stepdown from psychiatric hospital, care homes, history of some low risk challenging behavior.

Referral Form

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