Agency Referral Form for Floating Support Services
Date:
1. Applicant details:
Date of Birth:
Mr / Mrs / Miss / Ms / Rev
Other:
Surname:
National Insurance Number:
Telephone Number:
Forenames:
Mobile Number:
Address:
Preferred 1st Language:
Nationality:
Postcode
Is Interpreter Required? ...
2. Referred by:
Contact Name:
Organisation:
Telephone Number:
Address:
Email Address:
@
Service User: *I consent to the information provided on this form being shared with the Supporting People Team,
relevant parties who have provided, who currently provide, or who may in the future provide me with housing
related support, and commissioners of support services.
Service User signature:
Date:
4. Current Accommodation: (Please Tick)
House/Flat
Hostel
Bungalow
Supported Housing
Bedsit
Lodging with Parent / Relative / Friend
Sheltered
Bed and Breakfast
Extra-care Sheltered
Temporary Accommodation
Nursing/Residential Care
Rough Sleeper
Refuge
Other (Please Specify) -
5. Client / Family Details & History:
Are You Pregnant?
Yes
No
Do you have dependant children?
Yes
No
Do you have access to dependant children? Yes
Surname
First Name(s)
If yes please give details
No
If yes please give details
Relationship
Gender
M
F
M
F
M
F
M
F
Age
M
Are there any children not mentioned above that you have regular access to? Yes
If yes please give details:
Surname
First Name(s)
Are you a care leaver aged under 21?
Relationship
Yes
F
No
M
Gender
F
M
F
M
F
M
F
M
F
Age
No
Are there or have there previously been any child safeguarding or child protection issues?
Yes
No
Not Applicable
For example:
Have or are the children subject to a Child Protection Plan?
Have the children ever had or do the children have a Social Worker?
Is there a history of contact with Social Services?
Do you have any concerns are the welfare or safety of the children?
If you answer ‘Yes’ to the above question we will contact you for more information.
Please note if you do not answer this question we will return the form to you.
6. Convictions
Do you have any spent convictions? Yes
No
Do you have any unspent convictions? Yes
Do you have any outstanding legal matters? Yes
No
No
(if no to all of the above please go to question 9)
If yes to any of the above please give details:
Please tick any convictions:
Arson
Drug Misuse Offences
Sex Offences
Firearms Offences
Driving Offences
Murder / Manslaughter
Assault or Violent Offences
Unlawful Entry
Deception
Robbery / Extortion
Other (Please Specify):
Please give details of your Probation Officer: (if applicable)
Name:
Address:
Telephone:
7. 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) ?
Are you currently in treatment for drug or alcohol misuse issues?
Would you be prepared to go into drug or alcohol treatment?
Alcohol
Illicit Drugs
Prescribed Drugs
Yes
No
Yes
No
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):
8. Mental Health Issues:
Do you have a Mental Health Diagnosis?
(If no please go to question 11)
What is it?
Yes
No
Do you have a Care Plan relating to any existing mental health diagnosis? Yes
Are you receiving any support for mental health issues? Yes
No
No
Worker Contact Details:
Name:
Telephone:
Address:
Are you currently receiving and treatment or taking any medication for mental health issues?
Yes
No
Please give details:
9. Physical Health Issues:
Do you have any physical health issues?
Yes
No
(if no please go to question12)
Please provide details of any physical health problems you have. This could be things like, mobility issues, epilepsy,
blood borne viruses like HIV, Hep C / B, cancer, breathing difficulties, etc:
Are you registered disabled?
Yes
No
Are you taking any medication for any health problems you have? Yes
If yes please give Details:
Who prescribed this medication:
No
10. Other Support Agencies Involved:
Agency
Contact Name and Telephone Number
Details of Support Received
11. Service User Client Group: Please indicate using numbers 1 – 3 the client groups you fit into in order of
importance (1 = most important)
Learning Disabilities
Drug Misuse Issues
Mental Health Problems
Alcohol Misuse Issues
Sensory/Physical Disability
Vulnerable Young Person
Teenage Parent (s)
Young Person Leaving Care
Older Person with Support Needs
Refugees / Asylum Seekers
Single Homeless with Support Needs
People with HIV / AIDS
Homeless Families with Support Needs
Offenders / at Risk of Offending
People at Risk of or Exposed to Domestic Abuse
Young Lesbian Gay Bisexual or Transgender
(Under 25)
Gypsy / Traveller/Showpeople
Other (Please State) :If this person is at risk of or exposed to domestic abuse have steps been taken to ensure their safety?
Yes
No
Are there or have there previously been any adult safeguarding issues relating to this client?
Yes
No
Not Applicable
Please note if you do not answer this question we will return the form to you.
Please explain the reason for referral:
12. Current Areas of Need:
Issue
Offending
Yes
No
Issue
Maintain Accommodation
Yes
No
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
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.
15. Is there a particular Service Provider you wish to provide your support?
(We will endeavour to refer you to your requested service, however cannot guarantee the Service Provider will provide
your support.)
Yes
No
Action for Children – ASSFAM FIP
English Churches Housing Association – SASH
Floating Support
Beacon Support – Floating Support
Salford City Council – Supported Tenancies
Creative Support – Supported Tenancies
Salford Drug and Alcohol Service – Tenancy Support
Service
16. How did you hear about the HSL?
Friend / Family (word of mouth)
Agency
Poster
Leaflet
Which?:
Where was it?:
Where was it?:
17. Risk Assessment
Please tick if any of the risks apply to the applicant and indicate the level of risk – high (H) medium (M) or low (L). Floating
Support services may need to enquire further about risk factors.
If you have completed your own risk assessment please forward a copy of it with this referral in addition to
completing this page.
Risk
To Staff
To
themselves
To others
From
others
H / M / L / None
Verbal aggression
Physical violence
Weapon carrying
Self harm
Self neglect
Suicidal thoughts
Drug / Substance misuse
Alcohol misuse
Medication / non-compliance
Bullying
Inappropriate sexual
behaviour
Arson
Theft
Damage to property
Abuse of professional
support services
Racial abuse
Non engagement with staff
Abandonment of property
Other
If you have not completed this section please explain why:
Please note if you fail to complete the risk assessment and do not explain why we will return the form to you.
Please provide details regarding the type of risk as indicated above e.g. is the risk historic or current and details
of why there is a risk:
Additional Information
Equality Monitoring Information
Ethnic Origin
Please note – ethnic origin questions are not about nationality, place of birth or citizenship. They are
about colour and broad ethnic group – UK citizens can belong to any of the groups indicated.
Please choose one section from A to E then tick the appropriate box to indicate your cultural
background.
A. White
English
B. Mixed
C. Black
White and black Caribbean
Black
Welsh
White and black African
Black British
Scottish
White and Asian
Caribbean
Irish
Any other mixed
background
(please specify)
African
Any other white
background
(please specify)
D. Asian
Asian British
E. Chinese
Chinese British
Any other black
background
(please specify)
F. Other ethnic group
Gypsy/ Romany
Indian
Chinese
Irish Traveller
Pakistani
Any other mixed
background
(please specify)
Any other ethnic
group
(please specify)
Bangladeshi
Any other Asian
background
(please specify)
Gender
Male
Female
Transgender
Have you had a change in gender since you were born i.e. male to female or female to male?
Yes
No
Religion/ Belief
Christian
Muslim
Buddhist
Sikh
Jewish
Hindu
None
Any other religion/ belief
(Please specify)
Disability
Salford City Council operates within the framework of the Disability Discrimination Act 1995, (DDA) which
defines disability as:
‘A physical or mental impairment which has substantial and long term adverse effect on a
person’s ability to carry out normal day to day activities’
Do you consider yourself to be disabled as defined by the Disability Discrimination Act?
Yes
No
(If you are unsure as to whether you should claim yourself as disabled, please call the Disability Rights
Commission helpline on: 08457 622 633).
If yes, what is your disability?
Learning difficulty
Dyslexia
Dyspraxia
Hidden impairment
Medical condition
Physical impairment
Sensory impairment
Prefer not to say
Hearing/ visual
Other
(Please specify)
Mental health difference
Age in Years
Under 16
16-19
20-29
30-44
45-59
60-64
65-74
75+
Sexual Orientation
Bisexual
Gayman
Heterosexual
Lesbian
Please return to: housingsupportlink@salford.gov.uk
Thank you