Birmingham floating support referral form Your contact details Name * Current address including postcode * Previous addresses Reason for leaving previous address/es * Date of birth Today Clear Age Home phone Work phone Mobile number Religion Housing benefit reference number (if applicable): Landlord (if applicable) Has the applicant got the right to remain in the UK? Yes No Expiry date Please note applicant will need to evidence at assessment stage. Today Clear Preferred language (Please state if an interpreter is required and does the service user require a translation of all paperwork) Next of kin details (Including name, address, phone number and email) Referral source Is this a self-referral? Yes No Referral agency details Please highlight below which type of organisation you are referring from: ACAP ASH Hub Community Mental Health Team Criminal justice agencies DA Hub Exempt Sector Accommodation Provider Health service/GP Housing Options Team Internal transfer Neighbourhood Network Services Offenders Hub Outreach Service Social Housing Accommodation provider Social Services Substance misuse services Voluntary organisation Youth Hub Other Contact name Agency Contact telephone number Email address Job role Referral form completed by and job role (if different from above) Diversity We are committed to meeting the diverse needs of its residents, achieving, and promoting racial equality and tackling prejudice and racial harassment. We can achieve these aims if we are aware of and record equality information. How would you describe your ethnic background White English/Welsh/Scottish/Northern Irish/ British Irish Gypsy, traveller, or Irish traveller Any other white background Mixed/multiple ethnic groups White and black Caribbean White and black African White and Asian Any other mixed/multiple ethnic background Black/African/Caribbean/Black British African Caribbean Any other black/African/Caribbean background Asian/Asian British Indian Pakistani Bangladeshi Chinese Any other Asian background Another ethnic group Arab Any other ethnic group Prefer not to state Sexual orientation Bisexual Lesbian Gay man Heterosexual Does not want to disclose Other Please state Family status Single Single pregnant Single lone parent Couple Couple with children Couple expecting Other Other, please state Gender Female Male Non-binary Transgender Cis-gender Not entered/not known Refused to answer Other Other, please specify Convictions/criminal history/history of violence Have you any unspent convictions for: Arson Yes No Violence and assault Yes No Drug related offences Yes No Possession of offensive weapons Yes No Sexual offences Yes No If yes to any of the above, please give further details Are you on the sex offender's register? Yes No If yes, what date will it expire? Today Clear Do you have a youth offending/probation officer? Yes No Youth offending/probation officer Name, email address and contact telephone number Recreational drug use/alcohol Are you currently taking any illegal drugs, substances or abusing any prescribed medication now inc. solvents/cannabis? Yes No If yes, please give the following details: What drug or substance? How often? How long have you been using? Are you receiving support for drug use? (drug interventions programme) Yes No If yes, please give the following details: Name of Service Contact Name Telephone Number Frequency of Meetings Do you drink any alcohol? Yes No Do you have an alcohol dependency? Yes No Are you receiving support for your alcohol use? Yes No Please give the following details: Name of service Contact name Telephone number Frequency of meetings Your support needs Do you need support to manage or improve your physical health? Yes No Do you need support to manage or improve your mental health? Yes No Have you accessed primary healthcare? Yes No Are you Registered with a GP? Yes No Name and address of GP (please include telephone number) Have you attended an annual health check? Yes No What was the date of this check? Today Clear Do you participate in leisure, cultural, faith, informal learning, and community activities? Yes No Do you have established contact with external services, family and/or friends? Yes No Do you need support to access to specific health programmes such as flu jabs and inoculations? Yes No Are you pregnant? Yes No If you have dependants, are you able to look after them without support? Yes No Do you work? Yes No If yes, please list employers name, working days/hours and length of employment Do you participate in voluntary work? Yes No If yes, please state details Are you currently residing in stable accommodation? Yes No Are you at risk of eviction? Yes No If yes, please give details Are you in temporary accommodation? Yes No If yes, when does your licence/tenancy end? Today Clear Are you able to maintain your home without support? Yes No Are you in Debt? Yes No Please give details: Are you able to manage your own finances without support? Yes No If no, please explain why Please give a brief description of your current circumstances and any additional information that will help us to process your application efficiently. E.g. currently homeless, not in receipt of benefits, domestic violence, antisocial behaviour, vulnerability, safeguarding concerns. Are you currently receiving support from any other Supporting People Services? Yes No If yes, please specify Your health and wellbeing In regard to your overall health and wellbeing have you ever had any support or sought advice from the following agencies? Birmingham City Council Community Advice services Your own family First point of contact Friends GP Health Service Mental Health Service Social workers Voluntary Agency Other Are you currently under the care management of Social Services? Yes No Please specify Social Worker name, department, email and telephone number Are you currently subject to any Section duty? Yes No Are you currently under a Deprivation of Liberty (DOLs) order? Yes No Have you have ever experienced the following Attempted suicide Self-harm Harm from others Self-neglect Relapse in relation to substance misuse Accidental harm Overdose None If you have circled any of the above then please describe in more details, including dates of events. Do you have a mental health diagnosis? Yes No How does your mental health diagnoses affect you daily? Are you currently supported by any mental health service? Yes No If yes, please give details including, name of service, name of practitioner, contact number and email Are you currently on any medication? Yes No If yes, please specify name of medication, dosage and frequency Disabilty We ask this question so we can make any necessary adjustments, if appropriate to do so, for you to receive our support. Do you consider yourself to have a disability? Yes No If yes, please explain Supporting information To help us fully understand your circumstances, it would assist us if you provided us with the relevant documents below. Please tick which supporting information has been submitted with this form Current pre-sentencing report Yes No Psychiatric report Yes No Current risk assessment Yes No Mental health supporting letters Yes No Drug agency supporting letters Yes No Alcohol agency supporting letters Yes No Current housing provider letters Yes No Social care/children’s services supporting letters Yes No Other Please upload any documents here Consent Name of applicant I consent to you processing my information. * Yes No
