<p> A1 Support Referral Form</p><p>A1 SUPPORT - REFERRAL FORM</p><p>Date of referral;</p><p>Referrers details:</p><p>Referrer’s name:</p><p>Details of involvement with applicant: </p><p>Organisation:</p><p>Address:</p><p>Contact Tel no</p><p>Email address</p><p>Applicants details:</p><p>First Name: Surname</p><p>Date of birth: Age:</p><p>Ethnicity:</p><p>Present address:</p><p>Type of current accommodation (e.g. family home, foster placement, hostel, secure accommodation etc)</p><p>Length of time at current address:</p><p>Contact No’s:</p><p>LDD/Disability needs: If so please give details</p><p>Reasons for making a referral to this organisation? 1 A1 Support Referral Form</p><p>Care/support plan already in place Yes No Please Attach </p><p>Please give a brief summary of the reasons why this young person is being referred to this organisation</p><p>What would the referrer and applicant agree are the main areas of support needed whilst living at one of our homes </p><p>What would the applicant like to achieve from living at one of our homes</p><p>Please indicate expected duration of placement </p><p>Housing history:</p><p>Please give a detailed housing history including any periods of homelessness</p><p>Has the young person ever been evicted? Yes/No</p><p>Has a Housing Application form been completed? Yes/No</p><p>2 A1 Support Referral Form</p><p>Risk Assessment - . Please give as much information as possible. It is important to receive a detailed holistic assessment of the young person’s needs and risk factors in order for the appropriate level of support to be provided. Details given will not necessarily exclude a young person from being offered a placement </p><p>Areas for consideration Yes / Please give details of the main concerns/issues including most recent No incident with approximate dates</p><p>Alcohol / substance use (I.e. excessive or problematic use of alcohol. Use of illegal substances and or concerns over use of legal / prescribed medication)</p><p>Domestic violence (I.e. experience of domestic violence in family home, perpetrator of domestic violence? fleeing domestic violence?)</p><p>Self injury (I.e. cutting, scratching, burning, pulling out of hair, banging head, punching self / walls, over dose, washing in toxic substances etc)</p><p>Police involvement / convictions (i.e. known to police, received cautions, been convicted of offences etc)</p><p>Has there been any history of arson? Y/N</p><p>3 A1 Support Referral Form</p><p>Areas for consideration Yes / Please give details of the main concerns/issues including most recent No incident with approximate dates</p><p>Aggression and Violence to peers (I.e. angry out bursts, threatening behaviour, physical violence, manipulation, bribery, gang affiliation etc</p><p>Aggression and violence to staff (I.e. angry out bursts, threatening behaviour, physical violence, manipulation and or bribery. Issues with lone working etc)</p><p>Child protection issues (Is the young person currently subject to child protection proceedings. Are there any risks posed to self or others. Any visitors /friends/ family subject to schedule 1 offences</p><p>Family issues (I.e. concerns over safety of family members. Family functioning, support mechanisms, contact issues etc)</p><p>4 A1 Support Referral Form</p><p>Areas for consideration Yes / Please give details of the main concerns/issues including most recent No incident with approximate dates</p><p>Mental health (I.e. ongoing, historical or significant emotional health issues. Prescribed medication and ability to safely administer etc)</p><p>Risk of exploitation (sexual, financial, emotional etc) (I.e. prostitution, involvement in drug / paedophile groups etc)</p><p>Maintaining safety and security of accommodation (I.e. insight into safe / unsafe situations. </p><p>Health and medication (I.e. ongoing or significant physical health issues. Prescribed medication and ability to safely administer)</p><p>Housing related issues (I.e. previous evictions, problems associated with tenancy / debt / benefits)</p><p>5 A1 Support Referral Form</p><p>Any information given relating to racial or ethnic origin, physical or mental health and criminal convictions constitutes sensitive data as defined by section 2 of the Data Protection Act 1998. I consent to the information given by me, including such information as constitutes sensitive data, being used, in accordance with the principles of the Data Protection Act 1998, for the purpose of processing my application and if successful in gaining a placement, for delivering services to me. </p><p>The above information is accurate and true to the best of my knowledge:</p><p>Signature of applicant: Date:</p><p>Signature of referrer: Date:</p><p>Please forward referrals to;</p><p>A1 Support Limited 66 Finnemore Road Bordesley Green Birmingham B9 5XT</p><p>6</p>