Floating Support Referral

1. Applicant’s details

Applicant's Full Name: (*Required field)  

Applicant's Date of Birth: (*Required field)  

Applicant's National Insurance Number (NINO):  

Applicant's Current address: (*Required field)  

Length of time at this address:  

Contact Numbers:

Applicant's Home Phone Number:  

Applicant's Mobile Phone Number:  

2. Other point of contact (eg friend or family member)

Name:  

Address:  

Relationship to Applicant:  

Contact number:  

3. Housing Status

4. Does the applicant have any of the following?

Please select all that apply:

• Drug problems

• Alcohol problems

• Frail elderly

• Mental health condition or disability

• Support needs

• Learning disabilities

• Mobility, muscular or physical difficulty

• Sensory impairment

• Any other medical issues

Comments about the applicant's needs:  

5. Is the applicant in contact with any of the following services?

Please select all that apply:

• Older People’s Support Services

• Community Mental Health Team

• Community Drug and Alcohol Team

• Other

Please give details of other services:  

Contact details

Contact's Name/Position  

Contact's Address  

Contact's Telephone number  

Contact's Email address  

Date of last contact  

6. Does the applicant have any special requirements?

Please select all that apply:

• Language

• Physical difficulty or sensory impairment

• Literacy/numeracy skills

Other details  

7. Risk Issues

If yes, please give details:  

8. Employment Status

Comments on the applicant's employment status:  

9. What are the applicant’s support needs?

Accommodation

Does the applicant need support in finding/keeping/managing their accommodation eg preventing eviction, managing rent/HB, dealing with neighbourhood issues? (Please select all that apply.)

• Finding accommodation

• Keeping accommodation

• Managing accommodation

• Preventing eviction

• Neighbourhood issues

Money/budgeting

Does the applicant need support in managing their money, setting up/paying bills, claiming benefits? (Please select all that apply.)

• Managing money

• Setting up/paying bills

• Claiming benefits

Life skills

Does the applicant need support/guidance with day to day activities eg cooking, cleaning, hygiene, correspondence, shopping? (Please select all that apply.)

• Cooking

• Cleaning

• Hygiene

• Correspondence

• Shopping

Health and wellbeing

Does the applicant need support with their health requirements eg contacting health services, GP, dentist, CMHT? (Please select all that apply.)

• Contacting health services/GP

• Contacting dentist

• Contacting CMHT

Enjoying and achieving

Does the applicant need support with finding work, training, volunteering opportunities and support? (Please select all that apply.)

• Finding training/education

• Finding volunteering opportunities

Community/social networks

Does the applicant need support with finding/attending social activities, meeting cultural/religious needs? (Please select all that apply.)

• Finding/attending social activities

• Meeting cultural/religious needs

• Support in relation to contact with external services

Other  

10. Please answer these questions to help us prioritise the application

If yes, give date/details about the eviction:  

If yes, please give date/details:  

If yes, please give details:  

Are you a care manager or key worker? If so, please complete risk screening form.

Risk Screening Form

Referral agencies: If you have completed a more comprehensive risk assessment through your involvement with the applicant, please do not complete this form, but include a copy of your most up to date risk assessment, including triggers and ways to minimise risks.

If you have not completed a risk assessment, then please use this form to highlight any potential/known risks for floating support staff to take into consideration when visiting/assessing the applicant.

If a risk assessment is already completed, please send us a copy.

Environmental

Detail any risk factors relating to the applicant’s accommodation or surrounding areas.

Please give full details of risk factors:  

Who may be directly at risk? Please give full details:  

Vulnerability

Please advise any risk to the applicant from others.

Please give full details of vulnerability issues:  

Risks from the applicant

Any known risks to others for example:

• Physically/sexually abusive

• Verbally abusive

• Weapons

Other risks from the applicant. Please give full details:  

Who may be directly at risk?

Please give full details of who might be directly at risk:  

Any known mental health conditions or disabilities, please advise

Please advise of any risk to the applicant from others.

• Physical

Other risk - please give full details:  

Drug/alcohol

Any known problems in this area, details of the extent of the problem, whether any help is being sought.  

Who may be directly at risk?

Please select all that apply.

• Neighbours

• Floating Support staff

• Other agencies

Other  

Triggers  

Ways to minimise  

Who are Floating Support Staff at risk from?

Please select all that apply.

• Applicant

• Friends

• Relatives

Degree of danger?

Please give details (for example, two people should visit)  

About You

Your Full Name: (*Required field)  

Your Address:  

Your Email Address: (*Required field)