Section 1 Details of person / agency making referral – NB: If you are referring yourself, you do not need to complete this section. Please go to Section 2. Referrer’s name: Agency: Address: Phone: Email: Please confirm that the applicant is aware of and agrees to this referral being made: □ □ Yes No If please obtain consent before continuing. ‘No’, Section 2 Applicant Details – □ □ Is this your first referral to Floating Support? Yes No Name: Address: Postcode: Home phone: Mobile: Email: □ □ □ Date of birth: Gender: Male Female Transgender National Insurance number: How you prefer to be contacted? Please tick all that apply: □ □ □ □ □ □ Email Home phone Mobile Text Letter Other: □ □ Can we contact you safely at this address / on this number? Yes No If please give details: ‘No’, Are there any pets at this address? Please specify: Second Applicant / Other people living with you Second Applicant Name: □ □ Are there other people over 16 living and/or staying with you? Yes No Please list names & relationship to applicant: □ □ Are there children under 16 living and/or staying with you? Yes No Please list and dates of birth: Section 3 - Support Needs
Section 1 – Details of person / agency making referral NB: If you are referring yourself, you do not need to complete this section. Please go to Section 2. Referrer’s name: Agency: Address: Phone: Email: Please confirm that the applicant is aware of and agrees to this referral being made: □ Yes □ No If ‘No’, please obtain consent before continuing. Section 2 – Applicant Details Is this your first referral to Floating Support? □ Yes □ No Name: Address: Postcode: Home phone: Mobile: Email: Date of birth: Gender: □ Male □ Female □ Transgender National Insurance number: How you prefer to be contacted? Please tick all that apply: □ Email □ Home phone □ Mobile □ Text □ Letter □ Other: Can we contact you safely at this address / on this number? □ Yes □ No If ‘No’, please give details: Are there any pets at this address? Please specify: Second Applicant / Other people living with you Second Applicant Name: Are there other people over 16 living and/or staying with you? □ Yes □ No Please list names & relationship to applicant: Are there children under 16 living and/or staying with you? □ Yes □ No Please list and dates of birth: Section 3 - Support Needs
2.2.3-Housing-Support-Oxon-Referral-Form.docx