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National Support Housing

National Support Housing
Referral Form

National Support Housing cannot accept referrals for any type of sexual offenses or behaviour (spent or unspent),

arson offenses, or high-risk violent offenses due to insurance purposes

AP01 Referal Formmmmm.pdf

* Please complete and submit the e-form or download the PDF File to return by post or email to exempt@nationalsupporthousing.org.

Accommodation Details

Date Accommodation Required * required

Referral Date * required

Client Information

Full Name

Contact Number

Current Address

Date of Birth (DOB) * required

National Insurance (NI) number

Referrer Information

Referrer's Name

Company

Contact Number

Email Address

Previous Involvement

Have you been a tenant of National Support Housing before?

Have you been referred to National Support Housing before?

Preferred Area

Accrington

Wigan

Skelmersdale

Burnley

Any

What area does the client have a local connection to?

Risk Assessment

Risk to children? YES / NO, if YES, choose Risk Level

NO

LOW

MEDIUM

HIGH

Risk to self ? YES / NO, if YES, choose Risk Level

NO

LOW

MEDIUM

HIGH

Risk to other Clients? YES / NO, if YES, choose Risk Level

NO

LOW

MEDIUM

HIGH

Risk to Staff? YES / NO, if YES, choose Risk Level

NO

LOW

MEDIUM

HIGH

Risk to Female? YES / NO, if YES, choose Risk Level

NO

LOW

MEDIUM

HIGH

Arson? YES / NO, if YES, choose Risk Level

NO

LOW

MEDIUM

HIGH

Please provide information on any identified risks:

Other Information

Current medication

Substance misuse background (substance of choice)

Still actively using?

Previous criminal convictions

Probation Officer (if known)

Supported housing experience:

How long have you known the client and in what capacity?

Ability to work with people (including staff)

Client Abilities

Ability to think and reflect

Adaptability to new experiences

Communication skills

Ability to deal with own emotions

Motivation

Budgeting skills / ability to manage a license agreement

Support & Services

Previous recovery-based interventions

Willing to engage in support services?

Able to sustain tenancy without housing-related support?

Engagement with external services

Benefits client is claiming / Employment status

Additional Information

Do you have any further comments?

Signatures

Referrer’s Signature

Print Name and Date

Client’s Signature

Print Name and Date

The client is not present to sign but is aware that a referral is being made on their behalf:

Signature

Print Name and Date

Thanks for submitting!

National Support Housing

Suite 4, Station Street Business Centre, Merseyside, L35 0LP

01925-979-317

exempt@nationalsupporthousing.org

Company Nr: 13022052

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