Referral / Initial Assessment Form

Basic Information

Date: *

Time: *

Referrer: *

Referral Agency: *

Contact Number: *

Personal Details

Name of Referral: *

Phone Number: *

Allocated Address:

Date of Birth: *

National Insurance No:

Gender: *

Marital Status: *

Nationality: *

Ethnicity:

Religion:

Sexual Orientation:

Communication Needs:

Previous Address Information

Previous Address:

Postcode:

Type of Tenancy:

Reason for Leaving:

Reason for Supported Accommodation

Please tick at least 5 reasons to be considered for supported accommodation:

Select Reasons:
HomelessEx-offender requiring supportMental health issuesSubstance misuse issuesLearning difficultiesDomestic violence victimFinancial difficultiesLack of independent living skills

Residency

Are you a UK resident (leave to remain)? *
YESNO

Proof provided?
YESNO

Have you ever been refused from a Housing Scheme?
YESNO

Are you currently looking for alternative accommodation? (e.g. Council Housing)
YESNO

Reason for Homelessness / Tenant Background History

Please provide details:

Criminal Offences

Do you have any criminal convictions?
YESNO

Please specify these offences:

Date of Offence 1:

Type of Offence 1:

Sentence 1:

Date of Offence 2:

Type of Offence 2:

Sentence 2:

Date of Offence 3:

Type of Offence 3:

Sentence 3:

Are you subject to any orders? (DRR/Probation/Injunctions)
YESNO

If YES, please give details:

Is there a reason to be concerned about a risk to children?
YESNO

If YES, please specify:

Have you committed arson or damaged prior properties?
YESNO

Important: Expectations UK Ltd does not accommodate individuals with arson offences. Please contact the referrals officer for more information before continuing to complete this form.

Prison Released From:

Probation Officer Name:

Contact Number:

Address:

Family And Friends

Do you get any support from family and friends?
YESNO

Who is the support from?

How often do you receive support?

Would you like support to contact family and friends?
YESNO

Substance Misuse

Are you now, or have you ever been dependent on drugs or any other substances?
YESNO

Substance Details:

Type of Substance 1:

Amount Taken Per Day:

Length of Dependency:

Type of Substance 2:

Amount Taken Per Day:

Length of Dependency:

Do you have a drug worker?
YESNO

Drug Worker Name:

Company:

Contact Number:

Prescription Information:

Alcohol

Are you now, or have you ever been dependent on alcohol?
YESNO

Type of Alcohol:

Amount Consumed Per Day:

Length of Dependency:

Do you consider alcohol to be an issue for you?
YESNO

Do you have an alcohol worker?
YESNO

Contact Name:

Company Name:

Contact Number:

Prescription Information:

Physical And Mental Health

Registered at GP:
YESNO

GP Name:

Surgery:

Surgery Address:

Phone Number:

Date Registered:

Do you have any physical health conditions? (including learning difficulties)
YESNO

Physical Health Condition:

Diagnosed Date:

Have you been diagnosed with any learning difficulties?
YESNO

Please specify:

Are you currently, or have you ever received any support for your learning difficulties?
YESNO

Please specify the support received:

Would you like to start receiving support?
YESNO

Mental Health

Do you have any mental health conditions?
YESNO

Mental Health Conditions:

Diagnosed Date:

Does your mental health affect your behaviour?
YESNO

Please specify how it affects your behaviour:

Is there a current or past risk of self-harm or suicide?
YESNO

Please give details:

Medication

Are you currently taking any prescribed medication(s)?
YESNO

Please list your medication:

Medication 1:

Dosage:

Medication 2:

Dosage:

Medication 3:

Dosage:

Medication 4:

Dosage:

Medication 5:

Dosage:

Medication 6:

Dosage:

Do you require prompting to take your medication?
YESNO

Please specify how often you require prompting:

Finances

Benefits:

Amount Per Week/Month:

When was the claim made?

Was housing benefit claimed previously?
YESNO

Do you have any debts?
YESNO

Please provide details:

Do you have any issues with gambling?
YESNO

Please provide details:

Do you require support with:

Budgeting:
YESNO

Managing your money:
YESNO

Keeping up to date with your service charge:
YESNO

Please specify the support required:

Do you require support with your correspondence/letters?
YESNO

Personal Hygiene

Please tick the areas below in which you would like to receive support:

Support Areas:
Shower/BathChange clothesDo laundryChange bed linenClean/tidy communal areasClean/tidy bedroomOther

Please specify support required for selected areas:

Is there a current or past risk of self-neglect?
YESNO

Please specify:

Allergies

Do you have any allergies?
YESNO

If YES, please tick your allergy(s) below and provide details including: what you are allergic to, the reaction you usually have, if you have an EpiPen, medical bracelet etc.

Allergy Types:
Drug/Medication AllergyFood AllergyInsect AllergyLatex AllergyMold AllergyPet AllergyPollen AllergyOther Allergies

Please specify all details about your allergies:

When was your last reaction?

Appointments

Do you require support for the following appointments?

GP:
YESNO

CPN/Psychiatrist:
YESNO

Benefit / Job Centre:
YESNO

Dentist:
YESNO

Opticians:
YESNO

Any Other:

Needs Assessment

Please select the NEEDS of the resident in the SUPPORT PLAN

Achieve Economic Wellbeing

Select needs:
Accessing benefitsBudgetingReducing debtSetting up a bank/savings accountLearn how to shop wiselyRecoup monies owed

Be Healthy

Select needs:
Better manage/improve mental healthBetter manage/improve physical healthFollow a healthy dietMaintain good personal hygieneReduce substance misuse (drugs)Reduce substance misuse (alcohol)Register with a dentistRegister with a GP

Enjoy And Achieve

Select needs:
Access training/educationAccessing employmentAccessing leisure, faith or cultural activitiesAccess volunteeringMove onSupport with equality and diversity

Making A Positive Contribution

Select needs:
Establishing positive support networksAddress anti-social behaviourAddress offending behaviour

Stay Safe

Select needs:
Develop independent living skillsMaintain accommodationMinimize risk of harm

Confirmation

Confirmation: I confirm that all the information provided is true to my knowledge and agree to follow a program of support based on this assessment.

Client Print Name: *

Client Signature (Type your name):

Support Worker Print Name:

Support Worker Signature (Type your name):