Make a referral to Housing Support for adults in Leicestershire.

Service access criteria

Your Details

Email Email is invalid First name Last name Your relationship to the person Organisation name

Who are you referring?

First name Last name Known as Date of birth Email Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery NHS number

Additional referral details

Do not enter protected health information (PHI) or any other personal data in these fields. What are the reasons for this referral? Please share some brief details regarding this referral Referrer's Contact Details (email and phone): CLIENT PERSONAL DETAILS NI Number First Language Interpreter Needed ALTERNATIVE CONTACT (for contacting regarding appointment times etc.) Name Telephone Relationship to Service User Address SIGNIFICANT OTHERS (children, partner, etc.) 1. Relationship to Client 1. Title and Name 1. Date of Birth 1. Telephone 1. NI Number 1. Address (if different from above) 1. Postcode 1. First Language 1. Interpreter needed 2. Relationship to Client 2. Title and Name 2. Date of Birth 2. Telephone 2. NI Number 2. Address (if different from above) 2. Postcode 2. First Language 2. Interpreter needed DOES THE CLIENT HAVE ANY OTHER SUPPORT WORKERS? 1. Name, Agency, Job Title, Telephone 2. Name, Agency, Job Title, Telephone 3. Name, Agency, Job Title, Telephone *** FOR ALL REFERRALS *EXCEPT SAP & TALK-2-SORT* CONTINUE TO - INCOME, NEEDS & RISK ASSESSMENT *** YOUNG PEOPLES NEED/RISK ASSESSMENT (SAP and talk2sort only) Parent/Carer Names(s) Relationship to YP Address Postcode Telephone Mobile Is the YP aware of referral? Has the YP consented to engage with our service? Is the parent/carer aware of referral? Has the parent/carer consented to engage with our service? Please provide full details of the issues experienced by the young person/family members, including any known risks REASON FOR REFERRAL Please provide full details of issues experienced by the YP and/or family members, including both issues within school and the home. *** FOR REFERRALS TO SAP PLEASE SKIP TO *HOUSING & HOMELESSNESS NEEDS* *** *** FOR REFERRALS TO talk2sort PLEASE SKIP TO *CLIENT CONSENT SECTION* *** SOURCE OF INCOME NEEDS/RISK ASSESSMENT Is the service user vulnerable? If yes, give details why History of Physical disabilities/ conditions History of Mental Health issues Medication details Learning Difficulties History of substance misuse (Detail what and when last taken) Criminal offences & involvement with the Police (please email pre-cons if current probation/YOS Worker) Are they currently tagged? (If yes, please state date this ceases) Are any exclusion orders in place? (If yes, please detail where) History of Violence History of Violence (provide details) History of Exploitation, Vulnerability or Domestic Violence (provide details) Recent Major Life Changes (e.g. bereavement, relationship breakdown etc.) Self-Neglect (i.e. poor hygiene, under/over medicating, malnourishment etc.) Difficulties Reading, Writing, or Speaking English Are you aware of any risks to staff from the service user or anyone in the household? (if yes please give details including any risk posed by the property, environment and pets) Does this service user require anybody to be with them at the assessment? (if yes please give details) ** HOUSING AND HOMELESSNESS CIRCUMSTANCES - For all referrals (except talk2sort) ** PLEASE COMPLETE THE BELOW IF THE CLIENT CURRENTLY HAS A TENANCY Are they an Owner Occupier? Landlord details Date moved in Rent Arrears (if any) Is there any Legal Action that threatens their security of tenure?** **If yes: Has the Client been offered a new tenancy? (if yes please give address/landlord) Give details of the housing support needed to prevent homelessness PLEASE COMPLETE THE BELOW IF THE CLIENT IS CURRENTLY HOMELESS OR HOMELESS WITHIN 56 DAYS Has the Client made a Homeless Application?** **If yes, Homelessness Reference Number and Case Officer: Has a PHP been issued? (Please send us the referral form) Is their reason to believe that this person in Priority Need as defined by S.189 of the Housing Act 1996 Local Authority/s where a Part 6 Connection is Held (Housing Register) Reason for Local Connection Local Authority/s where a Part 7 Connection is Held (Prevent/Relieve Homelessness) Reason for Local Connection Has a Full Duty Decision been issued? Is yes, confirm outcome: Have they applied for stayed in this service before? (Falcon Centre Referrals Only) Are they in temporary accommodation? Has the Client been offered a new tenancy? (if yes please give address/landlord) Details of 5 Year Housing History (please include boroughs and postcodes if known) 1. Address, Landlord, From, To, Reason for leaving, Arrears 2. Address, Landlord, From, To, Reason for leaving, Arrears 3. Address, Landlord, From, To, Reason for leaving, Arrears 4. Address, Landlord, From, To, Reason for leaving, Arrears 5. Address, Landlord, From, To, Reason for leaving, Arrears *** CLIENT CONSENT *** I hereby give permission for information relating to me and my housing/support needs to be recorded, processed and shared by, and between, the referring agency and The Bridge with the understanding that this will not be disclosed to third parties without prior consent (unless there is a risk of harm to myself/others or criminal activity) Is verbal consent given? Whilst accessing services from The Bridge (East Midlands), please tick any method of contact that you *do not* wish the organisation to contact you by. Agency referral only: Consent gained for referral to be sent and for referral details to be stored securely by The Bridge (East Midlands)

Confirmation and consent

required