BFSS Self Referral Form
Your Name :
Your Address :
Telephone Number:
Email Address:
District Council Area Where you Live : AVDC / WDC / CDC / SBDC
Date of birth:
Date you are sending this Referral:
Do you speak English? Yes / No
If you don't speak English:
Which language do you speak?
Do you know someone who can translate for you?
Yes / No
Name of translator :
Telephone Number:
(if you don't know anyone who can translate for
you we will try to find someone)
If someone is helping you to complete this form, please give their :
Name:
Telephone Number:
Organisation Name (if any) :
Relationship to You :
How did you hear about BFSS?
Please ensure that you complete each section so that we can understand your situation. If
this form is not fully completed it may be returned to you.
If you need help to complete this form please call us on 01296 484322.
If a section does not apply, please write N/A in the space provided.
Details of where to send your completed Referral can be found on the last page of this
document.
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Who helps to support you at the moment?
Support Network
Members
Names
Contact Details
(Phone Numbers
etc)
Can we contact
them for further
information?
Yes / No
Close Family
Members
Carers
Citizens Advice
Bureau
Doctor
Psychiatrist
Midwife
Health Visitor
CPN – Community
Psychiatric Nurse
Complex Needs
Social Worker
Support Worker
Probation Officer
SCAS
SMART
Oasis
Other Support
(please specify)
(including close
friends)
Do you have any temporary physical health problems, mental health issues or long
term disabilities? Yes / No
If you would like to give us more information about your health, please write here:
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We will need to talk to you on the phone before we visit you.
When is the best time to contact you on the phone? _____________________________
If we cannot get hold of you on the phone number you have given, is there someone else
we can talk to who can get a message to you?
Name of Contact: ________________________________________________________
Their phone number: _____________________________
Tell us about your Housing Support Needs
Tell us about where you are living now
Are you renting?
Y/N
Do you have a mortgage?
Y/N
Are you about to be evicted?
Y/N
Are you homeless?
Y/N
Lodger or living with your family
Y/N
Will you need help with any of the following things: put a tick (√ ) n the box
Completing Forms such as Housing Benefit forms
Rent arrears / debt
Budgeting
Finding suitable accommodation
First tenancy or Keeping your tenancy
Property repairs and maintenance
Neighbour disputes or Anti-social Behaviour
Being new to the area
Parenting skills
Setting up standing orders and direct debits for household bills
Other (please give details)
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Please provide some information as to why and how you need support?
Continue on a separate sheet if necessary
Personal History Summary
This information is required to allow support staff to prepare for the assessment interview.
Do your have any history of the following?
Yes
Aggression – towards
other people either
verbal or physical
Arson
No
Yes
No
Self Harm
Sex Offences
Domestic Abuse – either
by you or to you
Do you have pets living in
the home?
What sort of pets?
Substance / Alcohol use
Other (please specify)
Are there any reasons why it may not be safe to visit you at home?
Yes/ No /Sometimes
If Yes or Sometimes: please give more details about why or when it might not be safe to
visit you.
Are there any other safety issues that you want to warn us about?
We will contact you if we intend to visit you. If it's unsafe to visit you at home, we will arrange to
meet you somewhere else.
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Who else is living at the address and what relationship are they to the you?
Name
Relationship to Applicant
Age
e.g. wife, lodger, son
if under 18:
Monitoring our Service
We want to provide a service, which is fair and available to everyone. To help us
monitor this, please answer the following questions:
Gender:
Male 
Female 
Transgender 
Do you consider yourself to have a disability?
Yes 
No 
Your Ethnic Origin:
(Tick)
A – White British
Irish
Gypsy, Romany, Irish
Traveller
Other
B – Mixed White & Black Caribbean
White & Black African
White & Asian
Other
C – Asian or Asian British Indian
Pakistani
Bangladeshi
Chinese
Other
D – Black or Black British Caribbean
African
Other
E- Other Ethnic group Arab
Other
F - Refused Refused / Not Given
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Thank you for taking the time to complete this form. Please return it by post to:
Bucks Floating Support Service
Claydon House
1 Edison Road
Rabans Lane
Aylesbury
Bucks, HP19 8TE
Tel: 01296 484322
Alternatively you can return it by:
Scan / email to: bucksenquiries@connectionfs.org
Please type: 'Referral' on the Subject Line
Or Fax to: 01296 436542
What happens when we get your referral?

When we receive the form it will be given to our allocations team for a decision to
be made on how we can help you. We will normally contact you within a few days.

We may need to come out to visit you in order to get more detailed information on
how we can help you.

If we need to visit you we will ring you to make an appointment, so please make
sure that you have given us telephone numbers where we can contact you.

If we cannot contact you by phone, we will send you a letter offering an
appointment. We will ask you to ring us to confirm the appointment. If you don't
confirm the appointment, your appointment may be cancelled.

If we are not the best people to help you we will tell you if there is somewhere else
where you can go for further help.

If you want to know the progress of your referral, please ring 01296 484322. The
office is normally open between 9.00 - 5.30 pm Monday to Friday.
Keep this page so that you have the phone number for
the office if you need to contact us.
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