Please Ensure That You Complete Each Section, Otherwise the Form Will Be Returned to You

Referral Form

Applicants name : Current address :

Current District Council Area (e.g. AVDC)

Date of birth:

Telephone / Contact details: If we cannot get hold of him/her on the phone number you have given, is there someone else we can talk to who can get a message to him/her?

Name of Contact ______Their phone number ______

Date of referral:

Communication barriers / preferred language: None

Referrer’s Name:

Organisation:

Tel numbers:

E-mail address:

Please ensure that you complete each section, otherwise the form will be returned to you. If a section does not apply, please write N/A in the space provided.

If your organisation has a current Risk Assessment or Care Plan, this must be attached in order to avoid a delay in processing.

Applications can be sent by Post to: Connection Support, Claydon House, 1 Edison Road, Aylesbury, HP19 8TE, Scan or e-mail to: [email protected] (please write Referral on the Subject line)

Fax to: 01296 436542 1Revised May 2016 Network of Support

Support Network Members Names Contact Details

Close Family Members

Carers

Doctor

Psychiatrist

Complex Needs

Social Worker

Support Worker

Probation Officer

Midwife

Health Visitor

Other Support (please specify) (including close friends)

Please give details of any health or disability issues that are relevant to this referral:

2Revised May 2016 Support Needs – please provide FULL information

Describe the Applicant’s current housing situation (e.g. street homeless, sofa surfing, about to lose tenancy, unsuitable accommodation etc) Does the Applicant have language or literacy difficulties? (please give details) Will the Applicant need any of the Describe the difficulties he/she experiences and the type of following assistance? help required. Budgeting Claiming benefits Completing housing related forms Finding suitable accommodation First tenancy/Sustaining tenancy Maintaining property Neighbour disputes/ASB No support/social networks Parenting skills Rent arrears/debt Setting up standing orders/direct debits for household bills Other (please specify)

Additional information relevant to support needs or referral in general: What specific support do you want BFSS to provide?

Continue on a separate sheet if necessary Monitoring our Service

We are committed to providing a service, which is fair and available to everyone. To help us monitor this, please answer the following questions:

3Revised May 2016 Gender: Male  Female  Transgender 

Does the Applicant consider him/herself to have a disability? Yes  No 

Is the Applicant a Veteran? Yes  No 

Ethnic Origin of Applicant: (Tick) A – White British Irish Gypsy, Romany, Irish Traveller Other B – Mixed White & Black Caribbean White & Black African White & Asian Other C – Asian or Asian British Indian Pakistani Bangladeshi Chinese Other D – Black or Black British Caribbean African Other E- Other Ethnic group Arab Other F - Refused Refused / Not Given

Risk Indicators Summary – Please mark against ALL indicators, or the assessment will be delayed. This information is required to allow support staff to prepare for the assessment interview fully. Does the Applicant have any history or evidence of the following? Don’t Don’t Yes No Yes No Know Know Historical Substance / Aggression Alcohol use Arson Sex Offences Domestic Abuse Self Harm Current Substance / Other (please specify) Alcohol use

Do you do lone visits to this applicant? Yes / No - Is there anything else that you feel we should know about this person in terms of risk (Please give details)

Has the applicant been accepted as requiring services under the following statutory frameworks? Care Programme Approach Yes  No  Don’t know  Probation Service or Youth Offending Teams Yes  No  Don’t know  Homeless and owed a main homeless duty Yes  No  Don’t know 

4Revised May 2016 Who else is living at the address and what relationship are they to the applicant? Name Relationship to Applicant Age e.g. wife, lodger, son if under 18:

Where did you hear about the BFSS service? (tick all boxes that apply) Used it Colleagues Family / Website Leaflet Library Other Agency Other (please before Friends (which one?) (which one?) give details)

Please ensure that you attach your current Risk Assessment and Care Plan.

What additional documents have you attached to this application?

…………………………………………………………………………………………

…………………………………………………………………………………………………

Confidentiality: It is our policy to share Referral information with the Applicant.

Is the Applicant aware of the content of this Referral? Yes / No Please ensure that the Applicant is aware that they will be contacted (usually by phone) before any intended visit, so that a Risk Assessment can be done.

BFSS will keep the information in this referral and the outcome of the referral confidential unless the Applicant agrees for it to be shared.

For completion by the Applicant:

Do you agree to the Referrer being informed of the progress and outcome of this referral? Yes / No

Signature of Applicant: ______

Name of Referrer:

5Revised May 2016 Signature of Referrer:

If you have information that you believe should not be shared, please contact the Allocations Manager, Service Manager or Operations Manager for further advice.

Thank you for taking the time to complete this form. Please return it with any attachments to:

Bucks Floating Support Service Claydon House 1 Edison Road Rabans Lane Aylesbury Bucks, HP19 8TE

Tel: 01296 484322 e mail: [email protected] .uk Fax : 01296 436542

6Revised May 2016