Initial Referral for Supported Accommodation

Please use this section to provide information about the person being referred.

Name: *

National Insurance Number: *

Date of Birth: *

Age: *

Gender: *

Ethnicity: *

Current Address/or care of: *

Phone Number: *

Email: *

Please tell us a little more about the current situation. What are the reasons for needing supported accommodation? What actions have been taken already? Are there any specific issues that we should consider?

Additional information: *

Do you have any physical or mental health concerns?: *

Are there any criminal convictions or ongoing involvement with the police? (for referral agents, please advise of any safeguarding concerns):

Please state any criminal convictions: *

Additional Information

Are you receiving any support from any of the following? Please provide name and contact number.

Social Worker:

NCC Homeless Team:

Probation Officer:

Community Mental Health:

Drug or Alcohol Services:

Other:

Are you making this referral on behalf of someone else?

If so, please provide your contact information below so we can provide feedback on the referral.

Agent Name:

Job Title:

Organisation:

Agent Phone Number:

How did you hear about Barnabas Safe & Sound?:

CONSENT
Under General Data Protection Regulation (GDPR) 2018 it is a requirement to obtain consent to store and share information about you with other agencies and organisations who may be involved in providing support services to you. Barnabas Safe & Sound maintain data to provide a range of support services. All data is stored securely and is only used for the provision of support services. You have a right to prevent this and therefore, do not have to consent if you do not want your information to be shared. However, it would be difficult for Barnabas Safe & Sound to offer supported accommodation without consent, but we may still be able to signpost you to other services in the area.

Referral Agents: Please tick to confirm you have the applicant’s verbal authorisation.

DECLARATION
I confirm that the information contained in this document is true and includes all relevant information.

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Initial Referral for Supported Accommodation

Please fill in the form below

Please use this section to provide information about the person being referred.

Your Living Arrangements

Additional Information

Are you making this referral on behalf of someone else?

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