Treasures Foundation is a registered Charity No: 1131292 and a company limited by guarantee in England and
Wales, No 6937026 Address:8 Trienna Court, Wendover Gardens, Hutton, Essex, CM13 2HD, Email:
info@treasuresfoundations.org
Welcome to Treasures Foundation (TF)
We are a charity that provides accommodation and support for women who have a history of
drug abuse and offending. The aim of the foundation is to break the cycles of addiction and
offending behavior. We embrace women of all races, cultures, ages, sexual orientation,
religious beliefs and social class. We provide a physically, psychological, emotionally safe
environment were women live in a culture of abstinence, have access to one to one support,
group work, alternative therapies and liaise with other supporting agencies for continuity of
care in order to develop self worth, confidence and empowerment to reach their full potential
achieve greater independence.
If you believe you are ready and can be apart of our community please complete the initial
application / referral below with your declaration and the confidentiality and sharing of
information form. Any information we have about you is kept confidential within Treasures
Foundation and stored securely except when we have a duty to share information or if you
give us permission to share information.
Please email these documents to referral@treasuresfoundation.org. If you would like to speak
to someone about your application please contact Mandy on 07950585947. We will contact
you or your referrer within ten days to arrange a full assessment and interview to discuss
whether Treasures Foundation supported housing is the right place for you.
All service users are risk assessed to ensure safety of our premises, staff and other service
users. We accept people who have low-level physical or psychological disabilities who are
responding to medication. We regret we cannot accept people who have been convicted of
arson.
APPLICATION / REFERRAL FORM
REFERRERS DETAILS (if applicable)
Referrers Name
Referrers Position
Referrers Agency
Referring Agencies Address
and Postcode
Telephone Number
Email Address
Fax Number
1
Treasures Foundation is a registered Charity No: 1131292 and a company limited by guarantee in England and
Wales, No 6937026 Address:8 Trienna Court, Wendover Gardens, Hutton, Essex, CM13 2HD, Email:
info@treasuresfoundations.org
How long has the applicant been known to you and in what circumstances?
PERSONAL / CLIENT DETAILS
First Name
Surname
Clients Current Address and
Postcode
Telephone Number
Email Address
Prison Number
(If applicable)
Estimated Date of Release
(If applicable)
PERSONAL / CLIENT DEMOGRAPHICS
Date of Birth
GP Registered
(Please state)
You will be required to give Treasures Foundation permission to contact your GP and acquire
a medical report prior to your admission in order to facilitate and support your recovery. Is this
agreeable with you?
Ethnicity:
Please tick the box that best describes your ethnicity and if you were born in the UK
White British
White Irish
UK born
Yes
No
2
Treasures Foundation is a registered Charity No: 1131292 and a company limited by guarantee in England and
Wales, No 6937026 Address:8 Trienna Court, Wendover Gardens, Hutton, Essex, CM13 2HD, Email:
info@treasuresfoundations.org
White Other
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Mixed Other
Asian Indian
Asian Pakistani
Asian Bangladeshi
Asian Other
Black Caribbean
Black African
Black Other
Chinese
Other
Religion:
Please tick the box that best describes your religious beliefs
Christian: Catholic, Protestant, Mormon,
Baptist etc.
Buddhist
Hindu
Jewish
Muslim
Sikh
Other
No Religion
Sexual Orientation:
Please tick the box that best describes your sexual preferences
Heterosexual
Homosexual
Bisexual
Transsexual
REASON FOR REFERRAL and SUBSTANCE MISUSE HISTORY
Please indicate the reason for this application / referral:
Please indicate which substances legal and illegal which have been used in the past:
Alcohol
Ecstasy
Amphetamine
Hallucinogens
Antidepressants
Heroin
Barbiturate
Methadone
Benzodiazepine
Opiate Other
Cannabis
Solvents
Cocaine
Other
Crack Cocaine
Other
Please state the last time substances were used and the reasons for stopping the drug use:
3
Treasures Foundation is a registered Charity No: 1131292 and a company limited by guarantee in England and
Wales, No 6937026 Address:8 Trienna Court, Wendover Gardens, Hutton, Essex, CM13 2HD, Email:
info@treasuresfoundations.org
Please indicate which substances legal and illegal that is been used currently:
Alcohol
Ecstasy
Amphetamine
Hallucinogens
Antidepressants
Heroin
Barbiturate
Methadone
Benzodiazepine
Opiate Other
Cannabis
Solvents
Cocaine
Other
Crack Cocaine
Other
Are you currently being prescribed methadone or another substitute?
As we are abstinence based would expect all service users to reduce their medication
and be substitute free in eight weeks. To be accepted into the accommodation you
must agree to a detox plan and sign a contract prior to moving in. We will support your
decision and liaise with your medication provider. Would you be willing to agree to
this?
Please note the storing, using alcohol or drugs on the premises is not permitted at
Treasures Foundation.
Declaration:
I would like to be considered for a place at a Treasures Foundation home. I confirm
that this information is accurate and complete and I understand that if any of it is false
I could be evicted.
Applicants Name
Applicants Signature
Date of application
Referrers Name
Referrers Signature
Date of application
4
Treasures Foundation is a registered Charity No: 1131292 and a company limited by guarantee in England and
Wales, No 6937026 Address:8 Trienna Court, Wendover Gardens, Hutton, Essex, CM13 2HD, Email:
info@treasuresfoundations.org
Treasures Confidentiality and Disclosure Form
Confidentiality and Sharing of Information
We are a charity that provides accommodation and support for ex-offenders coming out of
prison or women who are abstinent from illegal substances. We at Treasures ask you for
information about yourself in order to provide you with treatment to match your needs and
continuity of care. You have the right to access any information we have recorded about you
at any time. Any information we have about you is kept confidential within Treasures and
stored securely except when we have a duty to share information or if you give us permission
to share information.
Confidentiality is of vital importance and will be honored in all at all times but we have a duty
of care to share information with or without your consent under particular circumstances.
Whenever possible, we will discuss this with you first. We will share information:
1. If it is believed you are at risk of self-harm, suicide or risk of harm to any other person.
2. There is concern’s for the welfare of any children.
3. We believe you have used illegal substances putting your recovery in jeopardy.
Permission to share information.
We ask for your consent to share information with other services or professionals who are
important to your care or who hold important information about you. Anyone who receives
information from us is also under a legal duty to only use the information for the purposes you
have agreed to and must keep the information strictly confidential. These may include:
1. Other Drug Treatment Agencies, Gp’s and other Healthcare Services, DIP workers,
Probation Service, Department of Work and Pensions, Housing Departments, Social Care
Services, etc.
2. Shared information may include: care plans, previous treatment episodes, health issues,
including current medications, drug tests, treatment summaries, offending history etc.
Consent to Treatment and Information Sharing: I,
Name in capitals:
Signature:
Date:
5