Self referral form
Housing Support Link
Date:
1. Applicant details:
Date of Birth:
Mr/Mrs/Miss/Ms/Rev/Other:
National insurance number:
Surname:
Telephone number:
Forename/s:
Mobile Number:
Address:
Nationality:
Postcode:
Preferred first language:
Applicant: *I consent to the information provided on this form being shared with the Supporting
People Team and services who have provided, who currently provide, or who may in the future
provide me with housing related support.
Applicant signature:
Date:
2. Client / Family Details & History:
Are you pregnant?
Yes
Do you have dependant children?
No
Yes
If yes please give details
No
Do you have access to dependant children? Yes
Surname
First Name(s)
If yes please give details
Relationship
No
Gender
M
F
Are there any children not mentioned above that you have regular access to?
M
F
M
F
M
F
M
F
No
Yes
Age
If yes please give details
Surname
First Name(s)
Relationship
M
Are you a care leaver aged under 21?
Yes
No
Gender
F
M
F
M
F
Age
3. Convictions
Do you have any spent convictions?
Yes
No
Do you have any unspent convictions?
Do you have any outstanding legal matters?
Yes
No
Yes
No
If no to all of the above please go to question 4
If yes to any of the above please give details
Please give details of your Probation Officer: (if applicable)
Name:
Telephone:
Address:
4. Substance misuse issues:
Do you have a current/recent/history of substance misuse issues?
Yes
No
(If no please go to question 10)
Which substance/s (please tick all that apply)?
Alcohol
Illicit Drugs
Prescribed Drugs
Are you currently in treatment for drug or alcohol misuse issues?
Yes
No
Would you be prepared to go into drug or alcohol treatment?
Yes
No
Drug/alcohol worker contact details:
Name:
Telephone:
Address:
Please indicate the primary and secondary substances you currently, recently, or historically have
use(d):
Primary:
Secondary:
Prescription Drugs (Please Specify):
5. Mental health issues
Do you have a mental health diagnosis?
Yes
If yes, please describe
No
If no please go to question 6
Do you have a care plan relating to any existing mental health diagnosis? Yes
No
Are you receiving any support for mental health issues?
No
Yes
Worker contact details:
Name:
Telephone:
Address:
6. Physical health issues
Do you have any physical health issues?
Yes
No
(if no please go to question7)
Are you registered as disabled?
Yes
No
7. Other support agencies involved
Agency
Contact name and telephone number
Details of support received
8. Current areas of need
Issue
Yes
No
Issue
Offending
Maintain Accommodation
Drug misuse issues
Threat of eviction
Alcohol misuse issues
Domestic Abuse (or risk of)
Mental health issues
Avoid harm to others
Physical health issues
Harassment
Disability/specific needs
Obtain paid work
Maximise income
Participate in training/education
Reduce overall debt
Participate in work like activities
Obtain accommodation
Establish social networks
Develop confidence and
great
choice/control/involvement
Better manage self harm
Establish contact with external
services
Yes
No
Anti-social behaviour
Other – please give details below
Additional Information: Please use this space to tell us anything you have not done already or if you need
to expand on anything you have already told us.
9. How did you hear about the HSL?
Friend/family (word of mouth)
Agency
Poster
Leaflet
Which?
Where was it?
Where was it?
10. Is there a particular service you would like to provide your support?
Beacon Support
Housing Connections Supported Tenancies
Salford Drug Service Tenancy Support
Action for Children ASSFAM
Creative Support Tenancy Support Service
Great Places Renaissance Service
English Churches Housing Group SASH Floating Support Service
No Preference
Please note, while we endeavour to accommodate your wishes it may not be possible for your choice of
service to be granted in every instance.
10.
Declaration
I declare that the information I have submitted on this form is correct and complete as far as I know.
Applicant signature
If you are completing this form for someone else please give your details:
Name:
Address:
Relationship to applicant:
Telephone: