Is the applicant at risk of Yes No homelessness? Reason for leaving last accommodation? Does the applicant live Yes No alone? If no, please detail Contact details Applicant home telephone Applicant mobile telephone Applicant email address Preferred method of contact OR alternative contact details Other details Does the applicant have any communication issues? Are there any cultural issues we should be aware of? Please list any other type of support or services that are in place 1. Domestic Abuse 11. Chronic Illness (inc HIV & AIDS) (Men, Women & Families) 2. Learning Disability 12. Young Care Leavers 3. Mental Health 13. Young People (16 to 24 years) 4. Alcohol 14. Single Parent Families Indicate issues of the 5. Substance Misuse 15. Families applicant (please tick all that are relevant): 6. Criminal Offending History 16. Single People (25 to 54 years) 7. Refugee Status 17. People aged 55+ Physical/Sensory Disabilities Memory Loss/Dementia 8. 18. 9. Developmental Disorder 19. Generic 10. Dual Diagnosis 20. Multiple/Complex Needs From the above list please select the main support need (number): Type of Support Needed please tick if relevant – None A little Some A lot Setting up / maintaining home & tenancy None A little Some A lot Finance and budgeting None A little Some A lot Dealing with correspondence None A little Some A lot Maintaining the safety and security of the home None A little Some A lot Living skills None A little Some A lot Access to training and employment None A little Some A lot Accessing the community None A little Some A lot Managing relationships None A little Some A lot Physical / mental health and wellbeing
Is the applicant at risk of homelessness? Yes No Reason for leaving last accommodation? Does the applicant live alone? Yes No If no, please detail Contact details Applicant home telephone Applicant mobile telephone Applicant email address Preferred method of contact OR alternative contact details Other details Does the applicant have any communication issues? Are there any cultural issues we should be aware of? Please list any other type of support or services that are in place Indicate issues of the applicant (please tick all that are relevant): 1. Domestic Abuse (Men, Women & Families) 11. Chronic Illness (inc HIV & AIDS) 2. Learning Disability 12. Young Care Leavers 3. Mental Health 13. Young People (16 to 24 years) 4. Alcohol 14. Single Parent Families 5. Substance Misuse 15. Families 6. Criminal Offending History 16. Single People (25 to 54 years) 7. Refugee Status 17. People aged 55+ 8. Physical/Sensory Disabilities 18. Memory Loss/Dementia 9. Developmental Disorder 19. Generic 10. Dual Diagnosis 20. Multiple/Complex Needs From the above list please select the main support need (number): Type of Support Needed – please tick if relevant Setting up / maintaining home & tenancy None A little Some A lot Finance and budgeting None A little Some A lot Dealing with correspondence None A little Some A lot Maintaining the safety and security of the home None A little Some A lot Living skills None A little Some A lot Access to training and employment None A little Some A lot Accessing the community None A little Some A lot Managing relationships None A little Some A lot Physical / mental health and wellbeing None A little Some A lot
Floating-Support-FS1-Single-Referral-application-and-Risk-form-Oct-2015.docx