MAINSTAY REFERRAL FORM Referrals can be direct to assessment points or by email If you are completing this form electronically please expand the text boxes if necessary Date of referral AGENCY REFERRAL Referral agency name Is this a direct referral to one specific service in the MainStay Yes No Referrer’s name If yes which service are you referring to? Tel. n° Reason for referral Prison release date if applicable When they would like assessment-Today Within the week Specified date (Please Specify). Applicant’s Surname Applicant’s Forename M F Sex Date of Birth NI Number- Yes No Don’t Know Do not wish to disclose Pregnancy/Maternity - Is English their first language? Yes No (If No please Specify) Does the applicant communicate in English? Yes No Applicant Contact details - Further contact details for applicant- Preferred Contact Method Person to Contact Details Agency Details (if appropriate Applicants Current Address Postcode Address LA general Women’s refuge Short life housing Type of Housing association general Foyer Living with family accommodation Private sector tenancy Housing for older people Living with friends currently occupied Private sector leasing Residential care home Mobile Home/Caravan Tied housing or rented with job Hospital Any other temp accom Owner occupation (private) Prison Home Office/Asylum Owner occupation Approved Probation hostel Rough Sleeping Supported housing Children’s home/foster care Other Direct access hostel Bed and Breakfast Next of Kin- Address Name Phone Number Relationship Location of last Address settled accommodation Postcode Local Authority Area (if different from above) Disability None Mental Health Mobility Learning Disability Visual Impairment Autistic Spectrum Condition Hearing Impairment Other Progressive disability/Chronic Illness (e.g MS, Cancer) Does not wish to disclose Full-time work (24 hours or more per week) Not seeking work Economic Status Part-time work (less than 24 hours per week) Full-time student Govt training/Work Programme Unable to work because of long term sickness or disability Job seeker Other Adult Retired Immigration UK National Asylum Seeker EEA National Study/Work visa Status Leave to Remain White Mixed Asian or Asian Black or Black Other ethnic Gypsy, Refused Ethnicity British White & Black British British group Romany, Irish Irish Caribbean Indian Caribbean Arab Traveller Other White & Black Pakistani African Other ethnic White & Asian Bangladeshi Other group Other Chinese Other
MAINSTAY REFERRAL FORM Referrals can be direct to assessment points or by email If you are completing this form electronically please expand the text boxes if necessary AGENCY REFERRAL Date of referral Referral agency name Referrer’s name Tel. n° Is this a direct referral to one specific service in the MainStay Yes No If yes which service are you referring to? Reason for referral Prison release date if applicable When they would like assessment-Today Within the week Specified date (Please Specify). Applicant’s Surname Applicant’s Forename Sex M F Date of Birth NI Number- Pregnancy/Maternity - Yes No Don’t Know Do not wish to disclose Is English their first language? Yes No (If No please Specify) Does the applicant communicate in English? Yes No Applicant Contact details - Preferred Contact Method Details Further contact details for applicant- Person to Contact Agency Details (if appropriate Applicants Current Address Address Postcode Type of accommodation currently occupied LA general Housing association general Private sector tenancy Private sector leasing Tied housing or rented with job Owner occupation (private) Owner occupation Supported housing Direct access hostel Women’s refuge Foyer Housing for older people Residential care home Hospital Prison Approved Probation hostel Children’s home/foster care Bed and Breakfast Short life housing Living with family Living with friends Mobile Home/Caravan Any other temp accom Home Office/Asylum Rough Sleeping Other Next of Kin- Name Relationship Address Phone Number Location of last settled accommodation (if different from above) Address Postcode Local Authority Area Disability None Mobility Visual Impairment Hearing Impairment Progressive disability/Chronic Illness (e.g MS, Cancer) Mental Health Learning Disability Autistic Spectrum Condition Other Does not wish to disclose Economic Status Full-time work (24 hours or more per week) Part-time work (less than 24 hours per week) Govt training/Work Programme Job seeker Retired Not seeking work Full-time student Unable to work because of long term sickness or disability Other Adult Immigration Status UK National EEA National Leave to Remain Asylum Seeker Study/Work visa Ethnicity White British Irish Other Mixed White & Black Caribbean White & Black White & Asian Other Asian or Asian British Indian Pakistani Bangladeshi Chinese Other Black or Black British Caribbean African Other Other ethnic group Arab Other ethnic group Gypsy, Romany, Irish Traveller Refused