Refer someone for accomodation – Start Again Project

Referral Form

Step 1 of 17 - Referring Agency Details

Referral Form

All information in this form is confidential and will be treated with respect. Only information that will enable support to be provided for the young person will be requested. Information will not be released to other agencies without the young person’s consent. Form to be filled by referring agent and young person Please fill in ALL sections of the referral form in order for the application to be considered.

Referring Agency Details

Referrer Name

Agency

Contact Number

Position

Referral Date

Month

Day

Year

Young Person Details

Name(Required)

First Last

Gender(Required)

Male

Female

Prefer Not to Answer

Date Of Birth(Required)

YYYY

NI No.

Contact No.

Current / Previous Address

Street Address Address Line 2 City ZIP / Postal Code

Ethnicity

Religion

Main Language

Legal Status

British National(Required)

Yes

Has the young person entered the UK in the last 2 years?

Yes

Date of entry into the UK

Day

Month

Year

Nationality / Country of Origin

Guardian / Next Of Kin

Please can you provide the name(s), address and contact numbers of the significant people associated or connected to the young person.

Name

First Last

Address

Street Address Address Line 2 City ZIP / Postal Code Country

Contact No.

Relation to the young person

Guardian / Next Of Kin

Please can you provide the name(s), address and contact numbers of the significant people associated or connected to the young person.

Name

First Last

Address

Street Address Address Line 2 City ZIP / Postal Code Country

Contact No.

Relation to the young person

GP Details

Name

Address

Street Address Address Line 2 City ZIP / Postal Code

Contact No.

Health & Wellbeing

Please describe your current health including any medical conditions, allergies or medication required

0 of 2500 max characters

Please give details of any mental heath needs or concerns and/or input from Mental Health services

Do you use substance drugs or alcohol?(Required)

Yes

Please provide details including type of substance/drug/alcohol concerns

Have you been referred to a specialised agency regarding substance misuse. Please state below

Education / Training

College / Training Venue

Tutor's Name

First Last

Address

Street Address Address Line 2 City ZIP / Postal Code

Contact No.

Employment Details

Is the young person currently working?(Required)

Yes

Start date of employment

Month

Day

Year

Address

Street Address Address Line 2 City ZIP / Postal Code

Contact No.

Communication Skills

Please tick relevant column

Talking About Yourself

Excellent

Good

Poor

Discussing Things With Family

Excellent

Good

Poor

Discussing Things With Friends

Excellent

Good

Poor

Talking With Social Worker

Excellent

Good

Poor

Talking With Teachers / Employers

Excellent

Good

Poor

Independent Skills

Please tick relevant column

Prepare a meal

Excellent

Good

Poor

Shop for food

Excellent

Good

Poor

Wash dishes

Excellent

Good

Poor

Wash & Iron clothes

Excellent

Good

Poor

Clean bedroom & bathroom

Excellent

Good

Poor

Pay bills

Excellent

Good

Poor

Attend appointments

Excellent

Good

Poor

Income and Benefits

Are you claiming benefits?(Required)

Yes

Type of benefits

Amount Received

How Often

Daily

Weekly

Monthly

Other

Day Received

Is there any other agency involvement/support (please specify)

Agency

Contact Person

Support / Involvement

Legal Issues

Are you required to attend court?(Required)

Yes

If yes please provide details and future court dates

Does the applicant have a history with or current problem any of the following?

Has the applicant got any physical health issues?(Required)

Yes

If yes please explain

Has the applicant got any mental health issues?(Required)

Yes

If yes please explain

Name and Contact of GP/CPN

Has the applicant got any previous housing issues?(Required)

e.g. evictions/anti-social behaviour

Yes

If yes please explain

Has the applicant got any Learning Difficulties?(Required)

Yes

If yes please explain

Has the applicant got any Criminal Convictions?(Required)

Yes

If yes please explain

Has the applicant got any history of refusing support?(Required)

Yes

If yes please explain

Looked After Young Person

Is this young person subject to a care order?(Required)

Yes

If yes please provide details

Social Worker / PA name and contact details

[if different from above]

Are the LAC/Pathway/Support Plans/Risk Assessments in place?(Required)

Yes

Character Reference

The referring agency must provide a character reference of the young person to include information about the following.

Character Reference

What have been the success milestones for the young person so far?

What are the challenges and barriers the young person deals with?

What are the future aspirations for this young person?

Referrer Signature(Required)

I confirm the information given is entirely true

By checking this box, you confirm that the information given is entirely true and that if there is any additional information Start Again Project need to know to assess their needs fully, it will be given in the character reference.

Date(Required)

Month

Day

Year

Name

This field is for validation purposes and should be left unchanged.