Section 1 Details of Person / Agency Making Referral

Housing Support Referral Form (Oxfordshire)

1 Oxfordshire Housing Support Jan 2017 Section 1 – Details of person / agency making referral NB: If you are referring yourself, you do not need to complete this section. Please go to Section 2. Referrer’s name: Agency: Address:

Phone: Email: Please confirm that the applicant is aware of and agrees to this referral being made:

□ Yes □ No If ‘No’, please obtain consent before continuing.

Section 2 – Applicant Details Is this your first referral to Housing Support? □ Yes □ No Name: Address: Postcode: Home phone: Mobile: Email: Date of birth: Gender: □ Male □ Female □ Transgender National Insurance number: How would you prefer to be contacted? Please tick all that apply:

□ Email □ Home phone □ Mobile □ Text □ Letter □ Other:

Can we contact you safely at this address / on this number? □ Yes □ No If ‘No’, please give details: Are there any pets at this address? Please specify: Second Applicant / Other people living with you Second Applicant Name:

Are there other people over 16 living and/or staying with you? □ Yes □ No Please list names & relationship to applicant:

Are there children under 16 living and/or staying with you? □ Yes □ No Please list names and dates of birth:

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3 Oxfordshire Housing Support Jan 2017 Section 3 - Support Needs

Do you require support to maintain your home or tenancy? □ Yes □ No

3a. What type of accommodation are you currently living in? Please tick as appropriate:

□ Private rented □ Owner occupier □ Supported housing

□ Sheltered housing for older people □ Hostel □ Women’s refuge

□ Residential care home □ Hospital □ Prison

□ Probation hostel □ Mobile home / Caravan □ Temporary accommodation

□ Living with family □ Living with friends □ Rough sleeper

□ Local Authority / Council (please state which)

□ Housing Association (please state which)

□ Other (please give details)

3b. From the categories below, please tick all the support needs which apply to you:

- Economic Wellbeing

□ Income / benefits □ Debt management □ Work

- Enjoy & Achieve

□ Training / Education □ Leisure / Social activities □ Cultural needs

□ Communication □ Parenting / childcare □ Faith needs

- Be Healthy

□ Physical health □ Mental health □ Assistive aids and/or adaptations

□ Alcohol misuse □ Drug misuse

- Stay Safe

□ Maintaining accommodation □ Finding accommodation □ Setting up in new accommodation

□ Homelessness □ Independent living skills □ Immigration

□ Domestic abuse □ Offending behaviour □ Risk / harm management

- Make a positive contribution

4 Oxfordshire Housing Support Jan 2017 □ Confidence □ Motivation / Involvement □ Improving choice and control

5 Oxfordshire Housing Support Jan 2017 Section 4 – Support Network

Do you currently receive support from any of the following services? If ‘Yes’, please provide details, including any safeguarding concerns:

GP □ Yes □ No Social Worker (Adult services) □ Yes □ No Social Worker (Children’s services) □ Yes □ No Mental Health services / CPA □ Yes □ No Probation / Youth Offending Team □ Yes □ No Drug / Alcohol services □ Yes □ No Landlord / Warden □ Yes □ No Carer □ Yes □ No Hospital □ Yes □ No Other – please state: □ Yes □ No

Section 5 – Risk Assessment In order for us to manage any risk, please complete the following. Your answers will not affect our decision to offer support. However, this referral form will be returned to you if this section is not fully completed.

Have you been convicted of a violent or sexual offence? □ Yes □ No Have you misused alcohol? □ Yes □ No Have you misused drugs? □ Yes □ No Have you been subject to a Drug Treatment Order (DTO)? □ Yes □ No Have you been asked to sign an Acceptable Behaviour Contract (ABC) □ Yes □ No or Anti-Social Behaviour Order (ASBO)? Have you been treated in hospital for mental health □ Yes □ No or sectioned under the Mental Health Act? Have you self-harmed (including overdose attempts)? □ Yes □ No Are any of your behaviours a risk to yourself or others? □ Yes □ No Are you at risk from others? □ Yes □ No If you ticked yes to any of the above please provide details, including dates:

6 Oxfordshire Housing Support Jan 2017 Section 6 – Equal Opportunities

6a. To be eligible for Housing Support, at least one category must be selected from the list below:

□ Homeless family – i.e. Local Authority has found family to be ‘statutorily homeless’ and owed a main duty to provide assistance AND family is placed in temporary accommodation

□ Older Person (55 or over) □ Mental health problems □ Learning disabilities

□ Physical/sensory disability □ Alcohol misuse □ Drug misuse

□ Offender / at risk of offending □ Young person at risk □ Care leaver

□ At risk of domestic abuse □ Person with HIV / Aids □ Refugee

□ Teenage parents □ Rough sleeper □ Single homeless

□ Gypsy / traveller □ Generic / Complex needs / Other

6b. Communication / disabilities (Please tick as applicable) What is your preferred/first language? Do you need an interpreter? □ Yes □ No Do you have any disabilities? If Yes, please detail below

□ Mobility □ Visual Impairment □ Hearing Impairment □ Autistic Spectrum Condition

□ Mental Health □ Learning Disability □ Progressive disability/Chronic illness (e.g. MS, cancer)

□ Other – please state: □ I do not wish to disclose

6c. How would you describe your ethnic origin? White: □ British □ Irish □Other

Mixed: □ White & Black Caribbean □ White & Black African □ White & Asian □ Other

Asian or Asian British: □ Indian □ Pakistani □ Bangladeshi

□ Chinese □ Other

Black or Black British: □ Caribbean □ African □ Other

Other ethnic group: □ Arab □ Other ethnic group

Gypsy, Romany, Irish Traveller □

I do not wish to answer □

6d. How would you describe your sexual orientation? Please tick as appropriate. (optional – you do not have to answer this question)

□ Heterosexual / straight □ Gay man □ Lesbian

□ Bisexual □ Other □ I do not wish to answer

7 Oxfordshire Housing Support Jan 2017 6e. Culture / Religion

Do you have any cultural or faith/religious requirements? □ Yes □ No If Yes, please give details:

8 Oxfordshire Housing Support Jan 2017 Section 7 – Information

9 Oxfordshire Housing Support Jan 2017 Section 8 – Consent to share information

Referral form declarations

Do you consent to the information you provide being shared with others involved in your support?

□ Yes □ No Do you consent to us contacting or referring you to other agencies in relation to your support needs? □ Yes □ No

Applicant’s signature: Date:

Is there any specific information you do not want us to share, or are there any agencies with whom you do not wish your information to be shared? If so, please give details:

Important Note: If you do not give consent above, this may affect the service that is provided to you. If the applicant’s signature is not obtained at this stage we may not be able to gather information from other agencies, which may delay the referral process; Connection Support may request consent signatures at the assessment stage.

Please check that all sections of this form have been completed. If any required information is missing, this form may be returned to you, resulting in a delay to your assessment for Housing Support.

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