Positive Pathways
REFERRAL FORM
(PLEASE DO NOT COMPLETE AREAS IN ITALICS - FOR USE BY HUB ONLY)
Client ref
Date received by Hub
The below checklist is an essential criteria in order for
us to be able to consider the referral. The referral
cannot go ahead without this information.
Please complete this checklist once the referral is completed.
Provided (Please Tick)
Does the client Live / Wish to live in Leeds
Does the client have a local connection to Leeds?
Housing Need
Mental Health
FACE Risk - Or other suitable and appropriate risk assessment
Equal Opportunities
Service / Worker Preference - checked with client
Please return the form to: [email protected]
Positive Pathways
Community Links
Bank House
150 Roundhay Road
Leeds LS8 5LJ
Fax no 0113 200 9178
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SELF / REFERRAL FORM – Positive Pathways
SECTION ONE: Client Details:
Full Name:
Contact address:
Status:
Post Code:
Council RSL Private Owner Occupier Other: Please specify _____________
Date of Birth:
Contact number:
E-mail:
Do you have a Leeds Homes application?
YES / NO
Membership Number:
Referring Agency details completing on behalf of client (not to be completed for self-referrals):
Name:
Team/Agency address:
Contact Number:
Post Code:
Email:
Do you (the referrer) wish or need to be involved during our assessment?
YES / NO
Next of Kin / Emergency Contact Details:
Name:
Relationship to Client:
Address:
Post Code:
Contact Number:
Email:
SECTION TWO: Housing Need - Please provide details of your housing support need:
If you answer Yes to any of the below questions you must provide additional details in the boxes
Homeless or rough sleeping:
YES / NO
Sofa surfing or staying with friends:
YES / NO
Threat of eviction or home being
repossessed:
YES / NO
Issues concerning debts/arrears:
YES / NO
Unable to return to your property:
YES / NO
In severely unsuitable
accommodation (e.g. poor condition or
YES / NO
Add Detail:
Add Detail:
Add Detail:
Add Detail:
Add Detail:
Add Detail:
too large or small):
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Threatened with violence / abuse or
harassment where you are living:
YES / NO
Have you been offered a move, and
if so do you have a moving date?
YES / NO
Add Detail:
Add Detail:
If you are currently residing in a Hostel / Supported Accommodation:
Is there a discharge date
YES / NO
If yes, when?
Additional Housing Related Needs: Please provide details of any other housing needs
Is a move needed? If yes, add detail:
SECTION THREE: Mental Health - (Formal diagnosis is not required to access this service)
If you answer Yes to any of the below questions you must provide additional details in the boxes
Please provide details of any mental health support needs
Does the client consider themself to have issues
connected to mental health?
Please give further details
YES / NO
If you have answered No to the above question then we may not be the right service for you.
Is the mental health need considered to be long
and enduring?
YES /NO
Is the need considered to be serious and
complex?
YES /NO
Are there issues connected to substance misuse?
YES / NO
Additional Mental Health Details: Please provide any additional information that may support your referral
SECTION FOUR: Physical health
If you answer Yes to any of the below questions you must provide additional details in the boxes
Are there issues connected to physical health?
YES / NO
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Is there a disability?
YES / NO
Learning Disability:
If you answer Yes to any of the below questions you must provide additional details in the boxes
Is there a learning disability?
YES / NO
Is the client on the autistic spectrum?
YES / NO
SECTION FIVE: Other services involved
Is the client on the Care Programme Approach?
If yes, who is CPA co-ordinator (please include
contact details)
Please give further details
YES / NO
YES / NO
Details of any dependants living with the client:
Please give details of any other Agencies or professionals involved in supporting the client within
the past 6 Months
Worker / service
Name
Contact Number
Carer or significant other
Psychiatrist
GP
CMHT
Social Worker
Drug / Alcohol Services
Probation
Other :
Is the person at risk of disengaging from services?
YES / NO
Additional Details:
Preferred Language
(Please complete this
section for all clients)
Is an interpreter required?
YES / NO
Page 4 of 8
Requires specific contact method: (Please circle)
Audible Alert
Email
Letter
SMS
Telephone
Text Relay
Tactile Alert
Visual Alert
Did not want to state
Uses Hearing Aid
Citizen Advocate
Alternative Communication Skill
Uses Communication device
Deafblind Intervener
Uses Electronic note taker
Uses manual note taker
Uses Personal Communication Passport
Uses Makaton Sign Language
Uses Speech to text reporter
Communication Support Required: (Please circle)
Does Lip Reads
Legal Advocate
Uses cued speech transliterator
Uses Lipspeaker
Uses British Sign Language
Uses telecommunications device
Requires information in specific format: (Please circle)
Email
Electronic downloadable
format
Audio Cassette Tape
Contracted Grade 2 Braille
Easyread
Electronic audio format
Makaton
Moon Alphabet
Uncontracted Grade 1 Braille
Compact Disc
Digital Versatile Disc
USB
Written information in Large
Font
Information Verbally
Referrals to this service are allocated to the next available agency for assessment, unless a particular
agency or worker speciality is required.
Please tick which service is required (please leave blank if no preference):
Does the referred person have a Service Preference?
Community Links
Leeds MIND
St Anne’s
Touchstone
Leeds Irish Health & Homes
LCC Homeless Support
Team
LCC IMPACT Team
Does the referred person have a worker/specialist preference?
Black African Caribbean:
South Asian:
Drug & Alcohol:
Female:
Male:
Parent & Child:
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SECTION SEVEN: Information and Consent
Declaration:
As far as I know the information I have given on this form is true. I understand that providing false
information may result in housing and support being withdrawn.
I confirm that I have discussed this referral with those concerned and they have agreed to their data and all
relevant information collected in order to complete this referral to be shared with all parties involved.
Access to information:
I understand that in order to continue with this application information from other sources may be sought.
By signing below I give permission that any information which will help complete this application will be
provided.
I also give consent to those concerned with this application to share information that is relevant to help it
be completed.
Signed for / by or on behalf of applicant:
Name _________________________ Signature ____________________________ Date _______________
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Self Referral Risk Assessment
Your perception of risk (please rate the following):
Risk/Level
None
Low
Medium
High
Not known
Of suicide
Of deliberate self harm
Of accidental self harm
Of self-neglect
Related to physical
condition
Of abuse/exploitation
by others
Of violence/harm to
others
Of relapse
Of offending
Is the person being
referred subject to any
of the following? (Tick
MAPPA 
MARAC 
CAF 
CTO 
Probation 
as appropriate)
Is there any risk issues (including criminal convictions) involved
in visiting the client?
YES / NO / NOT KNOWN
If YES, please specify
Are there any pets/ animals living with the client?
YES / NO / NOT KNOWN
If YES, please specify
For agencies making the referral PLEASE ENCLOSE A FACE RISK ASSESSMENT (or other
appropriate risk assessment)
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Equal Opportunities
Positive Pathways strongly believes that particular groups of potential and actual service users are at risk of finding
services inaccessible, or of experiencing on-going poor mental health and poor quality of life, such as people from
Black or Minority Ethnic communities, Women, Gay men, Lesbians and Disabled people.
Because of this, we need to make sure that we are an accessible service and to do this we must monitor the
referrals that we receive to make sure that we are reaching all sections of society.
This page is designed to be detached from the rest of the form upon receipt. The information is anonymised ; it will
be stored separately from client files and used for monitoring and statistical reasons only.
How do you identify yourself (gender): (Please circle)
Male
Female
Do you live and work in the gender assigned at birth? (Please circle)
Yes
No
Did not want to state
How do you identify yourself (sexuality): (Please circle)
Lesbian
Gay
Heterosexual / Straight
Bisexual
Did not want to state
Other
What is your cultural background: (Please circle)
Did not want to state
White
Dual
Asian or British
Asian
Black or Black
British
Other Ethnic Group
British
White and Asian
Indian
Caribbean
Chinese
Pakistani
African
Gypsy/Traveller
Bangladeshi
Other
Other
White and Black
African
White and Black
Caribbean
Irish
Other
Other
Kashmiri
Other
Do you have a physical health problem that affects your life on a day to day basis, or consider yourself
physically disabled? (Please circle)
Yes
No
Did not want to state
Christian
Buddhist
None
Hindu
Muslim
Other
Sikh
Jewish
Did not want to state
Married
Co-habiting
Other
Civil Partnership
Single
Did not want to state
Do you have a religion: (Please circle)
What is your relationship status: (Please circle)
What is your residency status: (Please circle)
British Citizen
EU National
Refugee
Other
Asylum Seeker
Foreign Student
Destitute
Did not want to state
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