Universal Referral Form
1. Type of support required (please tick all that apply)
Debt & Finance Advice
Domestic Violence
Drug & Alcohol Services
Employment Ambition
Floating Support
Housing Ambition
Housing & Homeless Advice
Supported Housing
2. Client Details
Name (inc alias)
Current address
(including postcode)
If client is NFA please
give C/O address
Contact N°
Email
Date of Birth
NI No.
Gender
Male
Pregnant
Yes
Female
No
Due date
Transgender
Dependent children
Yes
No
3. Referrer Details
Referrer Name
Position
Agency Name & Address
(including postcode)
Tel. No.
Fax. No.
Email address
4. Next of Kin Details (optional)
Name
Address
Relationship
Contact No.
5. Current Accommodation Details (tick all that apply)
B&B
Council Tenancy
Friends/Family
Foster Care
Homeless (NFA)
Hospital
Hostel
Housing Association
Parental Home
Prison
Private Rented
Rehab Unit
Residential Care
Rough Sleeping
Supported Housing
Other
Landlord/Accommodation provider details
Name
Tenancy type
Organisation & Address
Contact No.
Rent arrears
Yes
V2 April 2016 Housing Ambition URF
No
Amount owed £
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Payment plan in place
Yes
No
6. Housing History (give details of accommodation over the last 5 years including hospital admissions, custodial sentences, periods
in detox units and periods of street homelessness)
Address
From
To
Accommodation type
Reason for leaving
Summary of historical and current housing issues (please tick all that apply)
Asked to leave
Anti-social behaviour
Care leaver
Current rent arrears
Escaping harassment
Escaping sexual abuse
Escaping violence
Eviction – ASB
Eviction – Rent arrears
Eviction – Property damage
History of ASB
History of abandonment
History of rent arrears
History of rough sleeping
Hospital discharge
Inability to cope
Leaving residential care
Mobility difficulties
Need supported housing
Never lived independently
Overcrowding
Outstanding repair issues
Relationship breakdown
Prison discharge
Tied accommodation
Other (please state)
Any other housing difficulties – Please highlight any identified patterns or other information in relation to the client’s housing.
(Evictions, Rent arrears, Anti-social behaviour, Neighbour Disputes or Excessive Noise etc)
7. Institutional History
From
To
Details
Armed Forces
Care
Prison
8. Employment & Training History
Employment/Training/Education details
V2 April 2016 Housing Ambition URF
Date from
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Date to
Reason for leaving
9. Benefits & Income
Benefit Type
Amount
Frequency Benefit Type
Care Leavers Allowance
DLA
Housing Benefit
Incapacity Benefit
Income Support
Jobseeker’s Allowance
PIP
Salary/Wages
Universal Credit
Other
Has the applicant received any Derbyshire Discretionary award in the last 6 months
If yes, please give details:
Amount
Frequency
Yes
No
Any other benefit difficulties – Please highlight any identified patterns or other information in relation to the client’s income
10. Debts
Debt
Total owed
Payment
Debt
Total owed
Has the applicant ever registered as bankrupt, had an IVA or are they under a debt management plan?
If yes, please give details:
Payment
Yes
11. Support Need & Medical History (please tick all that apply)
Alcohol dependency
Care leaver
Drug dependency
Ex-Offender
Fleeing Violence
Learning difficulties
Mental Health
Physical Health
12. Mental Health Details
MH Diagnosis
Key Characteristics & Support Requirements (please tick all of the following that apply)
Anxiety
Depression
Panic attacks
Paranoia
Personality disorder
Schizophrenia
Suicide attempts
Self harming
Additional information (please detail any medication taken and how their MH affects the applicant on a day to day basis):
V2 April 2016 Housing Ambition URF
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No
13. Physical Health Details
PH Diagnosis
Additional information (please detail any medication taken and how their PH affects the applicant on a day to day basis):
14. Substance Dependency Issues (please tick all of the following that the client uses)
Alcohol
Amphetamines
Cannabis
Cocaine
Crack
Crystal Meth
Heroin
Ketamine
Methadone
NPS
Prescription Meds
Solvents
Tranquillisers
Please give details of usage length of time using, level and frequency of use etc:
Other (please state)
15. Offending History
Offence
Conviction Date
Sentence received
Is the applicant subject to any bail/licence conditions or restrictions
If yes, please give details:
Yes
16. Current Support (please give details of applicants current support worker
Contact Name
Organisation
Contact No.
CPN
GP
MAT Team
Mental Health Service
Probation
Psychiatrist
Social Worker
Substance Misuse service
Housing Support worker
Banardos
V2 April 2016 Housing Ambition URF
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Support details
No
17. Risk Assessment
History of arson
Issues with males
Issues with females
Racist views
Homophobic views
Challenging behaviour
History of violence
Violent towards staff
Violent to service users
At risk of abuse
At risk of sexual assault
History of sexual exposure
Danger to children
Registered sex offender
VARM
MARAC
MAPPA
UNABLE TO RISK ASSESS
If any of the above have been ticked, please give further details of the nature of the risk(s) posed, to whom and the circumstances
which increase likelihood.
18. Further details on level of support required
19. Client consent & information disclosure
In order to help you to access housing and other related support services, we need your consent to access information about you
and share this with other agencies.
You need to be aware that information given to the service may be shared with other organisations and agencies. Information will
be shared on a need to know basis, where there is a specific and legitimate need to know. We will always disclose information to
agencies in exceptional circumstances, for example, where you pose a serious risk to yourself or others. The intention is to ensure
your safety and the safety and wellbeing of others.
We need to be able to share and obtain information about your case with and from a number of agencies to enable us to assist you
effectively.
By signing below you are giving us consent to this.
Client Name (please print)
Client signature
Date:
Referrer Name (please print)
Referrer signature
Date:
V2 April 2016 Housing Ambition URF
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