Agency Referral Form

Housing Services Referral Form

Please use this form to refer your clients to any of the following teams:

The Supported Housing Service - this service is made up of the following teams:

 Tenancy Support Service – This team provides practical support to anyone aged 26 plus who needs assistance before they obtain a home, in maintaining their current property or in setting up and obtaining a new one. Much of their work focuses on maximising income through budgeting and grant applications, but also assisting people with longer term goals such as education or employment. The service is open to council tenants, housing association tenants, owner occupiers and private tenants. For further information you can contact the team on (0191) 433 2731.

 Refugee Move on Service – A Refugee is someone who has been granted the right to remain in this country. The aim of this team is to help refugees integrate into the community assisting them to find accommodation and live independently in their tenancy through practical support and assistance. For further information you can contact the team on (0191) 433 3839.

 Domestic Abuse Support Service. This service offers practical and emotional support to both males and females suffering domestic abuse. The service is open to council tenants, housing association tenants, owner occupiers and private tenants whether or not that person has made a decision to leave the relationship. The service also has a number of safe houses available for people fleeing domestic abuse to temporarily reside in. For further information you can contact the team on (0191) 433 2622.

 Young Persons Support Service – This team provides practical support to anyone aged 16-25 years old who needs assistance before they are re-housed, in maintaining their current property or in setting up and obtaining a new one. For further information you can contact the team on (0191) 433 6826.

 Single Gateway Scheme – Working with support providers to re-house and support vulnerable people in the community who might otherwise be excluded from social housing i.e. ex offenders. This service works very closely with The Gateshead Housing Company to ensure a coordinated approach to support and housing. For further information you can contact the team on (0191) 433 2643.

 Health and Housing Support Team – This team assesses and supports people who apply to be re-housed on medical grounds as their medical condition is made worse as result of where they live. For further information you can contact the team on (0191) 433 2913.

The Housing Options Service – this service is made up of the following teams:

 The Housing Options Team – This service provides housing advice to the people of Gateshead. This includes assessing homelessness in order to establish when someone is in priority need for housing and also working with people to discuss options that could prevent homelessness. For further information you can contact the team on (0191) 433 3174

 The Debt Advice Team – This team assists and supports people with debt issues. They help people to resolve these financial issues by assessing their income and expenditure and contacting creditors where necessary to set up achievable repayment agreements. The team also operates the Mortgage Rescue Scheme on behalf of central government. For further information you can contact the team on (0191) 433 2642.

This referral form is to be completed by the referring agency with the person requesting support. As the referring agency you must ensure that the client has consented to this referral and this is evidenced on the signatures section of this form. Please complete all of the information in the white boxes, unfortunately if there are incomplete sections then the referral form will be sent back to you to be fully completed. Please note services such as the Single Gateway Service and the Health and Housing Support Team may need additional information from the applicant via a further more detailed application form.

© 2012 Gateshead Council Details of Referring Professional: Housing Services ReferralFor Form Office Use Only Name of Referrer: Date referral received: Name of Referring Agency: Referral Date: Date client acknowledgement sent: Address: Date referrer acknowledgement sent: Phone No: Relationship to the person being referred: Name of Support Worker handling referral:

Which housing advice/support service(s) does your client Date referral appointment arranged for: require? (Please tick box) Young Persons (16-25) Single Gateway E&D no: Tenancy Support (26+) Refugee Housing Options Domestic Abuse Date referral inputted on spreadsheet: Debt Advice Health and Housing Details of Person being Referred Title: Sex: M F Full name:

NI Number: Date of Birth: Age: Telephone no:

NASS Reference: Address: Refugee referrals only Date NASS Support ends: Refugee referrals only Housing Application Ref: Postcode:

Is it safe to contact the applicant at this address? Yes No If No, please provide an address that correspondence can be sent to:

Is it safe to contact the applicant on the phone number provided? Yes No If No, please provide a safe contact number and/or detail times they would prefer to be contacted at:

Is it safe to text? Yes No. Is it safe to leave a voicemail message? Yes No Name of any other household members Relationship to M/F D.O.B AGE (children/dependants/ husband/Partner) applicant

Applicants Current Housing Situation: Council Tenant Housing Association Tenant Private Tenant Owner Occupier Living with friends Living with family Temporary supported Local Authority Care Other (please state) accommodation Name of Landlord/Accommodation Provider: Landlord’s Contact Address: Contact number: Do you have any rent/accommodation arrears Yes No Unknown If yes how much? © 2012 Gateshead Council Reason for referral – what this person needs support with (please tick as many boxes as applicable) First Home Struggle with Help with benefit Currently/ Risk of eviction forms claim(s) recently Homeless Rent arrears Debt issues Budgeting Little support Rebuilding from family/friends confidence Domestic abuse Personal Safety Independent Feeling isolated Finding a job Living skills Accessing Greater Self Care Exclusion from More motivation education/courses independence council housing Anxiety or low Improving upon Learning Physical health A healthier moods parenting skills disability or disability lifestyle Communication To stop Drug misuse People around Granted the right i.e. language offending them are a bad to remain in the barriers influence. country Mental health Safeguarding Alcohol misuse Need to move on Ex Service Issues medical grounds Personnel Other reasons (please state)

Professionals currently involved (please give details of any other agencies involved with the client i.e. CPN, Probation, Social Worker) Name of professional Name of agency Contact address Contact no and job title

Risk Information: Does the applicant have a history of emotional or mental health issues? i.e. Depression, anxiety or self harm. Yes No If yes please detail what these are and how they are currently managed(including details of any medication):

Has the applicant had problems with alcohol misuse? Yes No If yes please state how much they currently drink and how often (if known):

Has the applicant had problems with drug misuse? Yes No If yes please state which substance, how much and how often they take them (if known):

Has this person ever committed any of the following crimes? Arson Yes No Violence to another person Yes No Use of or access to weapons Yes No Anti Social Behaviour Yes No If you have ticked yes to any of the above you must detail this further:

Have they offended within the past 6-12 months? Yes No If yes you must detail further what these offences were:

Have they ever been verbally abusive to staff or others? Yes No If yes please give details:

Are they experiencing any domestic abuse issues? Yes No If yes please give details:

Perpetrators name? M F D.O.B: Address? Is the perpetrator still living with them? Yes No Have they ever left the perpetrator before? Yes No

How would the applicant like to be contacted regarding this referral form? Letter Phone Text Email - please state email address:

Via another person – please state who this is and give contact details:

Other – please state:

Does the applicant need this information in any of the following formats? Large print Audio Type talk Braille

Other language – please state:

Does the applicant have any additional requirements? This could be cultural, religious, literacy needs, language/translator, preferred time or place of appointment, disability, access requirements etc. Yes No

If yes please give details:

As the referrer how did you hear about this service? Housing Services leaflet Poster Website Another agency The Gateshead Housing Company Colleague Other – please give details

Signatures

Professional making the referral I have shared all relevant information with Housing Services including any information I am aware of which may pose a risk to professionals lone working with this person. I am aware that if I have not disclosed something which may pose a risk I may be held accountable. Referrers signature: Date:

Person requesting support I hereby give my consent for Gateshead Council’s Housing Services to make enquiries about me and hold personal information received from all relevant agencies and services on my file. I understand that this information will be held in the strictest of confidence and held only to assist the support worker in their duties. However, I also understand that where there is a serious risk to another individual there may be a duty to share information. Signed by person being referred: Date:

If this form is sent via email and therefore written signatures cannot be obtained please type names in the signatures box and we will keep the email as evidence of the above agreements.

Please return this form to:

Supported Housing Assistant Single Point of Contact for Referrals Housing Services Community Based Services Civic Centre Regent Street Gateshead NE8 1HH

You do not have to answer the following questions however any information you do provide will be of great value to the council.

Any information provided will only be used for monitoring purposes to assist Gateshead Council to ensure that we provide a fair and equal service that is accessible to all members of the local community.

This information sheet will be separated from your personal details and will be completely anonymous and kept in accordance with the Data Protection Act.

Please return this form with the referral form to the postal or email address listed above.

Please tick the boxes which apply to you:

1. Gender:

Male Female Transgender Prefer not to say

2. Sexuality:

Gay Lesbian Bi-sexual Heterosexual

Prefer not to say

3. Disability:

Do you consider yourself to have a disability or any impairment? Yes No If yes please state what this is:

Prefer not to say

4. Ethnicity:

White British English Scottish Welsh Irish Other White background – Please detail:

Mixed White and Black Caribbean White and Black African White and Asian Other mixed background – Please detail:

Asian or Asian British Indian Pakistani Bangladeshi Other Asian background – Please detail:

Black or Black British Caribbean African Other Black background Other – Please detail:

Chinese Chinese Other Prefer not to say

5. Language

What is your first language?

What is your religion?