Referral Form for Professionals

Section A: Personal Information of Individual Being Referred:

Preferred Pronouns*

Date of Birth *

Address *

Street Address*

Street Address Line 2

City*

Postcode (Required)*

Phone Number (Mobile if Applicable) *

Email:

Who is their landlord? *
Local AuthorityRegistered social landlordTemporary AccommodationPrivate landlordLiving with family/friendsOwner/occupierOther

'Other': Please detail here:

Do they have other family or anyone else living at the address?

GP Details (if known)

Does the person you are referring have any language or communication needs?*
YesNo

Did the person you're referring serve in the armed forces? *
YesNoUnsure

Emergency Contact (if known)

First Name

Last Name

Phonetic Pronunciation of Name (optional)

Phone Number (Mobile if Applicable)

Email:

Section B: Housing Information:

Does the person you are referring require support with their housing situation? *
(i.e. Help to register with Leeds Homes, look for private lets, report repairs, has rent arrears or other debts putting their tenancy at risk/issues with landlord, query about council priority, resettlement support in new tenancy)
Please note if the person needs to move, but is bidding on the correct banding and not able to consider private lets, we are not able to help at this stage.
YesNo

What kind of support does the person you are referring require?*
Please tick each of the following that apply to the person you are referring:
Support required to make a planned move within LeedsSupport required to prevent homelessnessSupport required to manage in current tenancy

Please describe in detail the housing situation of the person being referred. *
Please note: This information is required to determine eligibility. If the box is left blank, we cannot continue with your referral.

Please submit the Leeds Homes bidding number (if known):

Please submit the priority band (if applicable):

Does the person you are referring have support needs that impact their ability to manage their housing situation independently? *
YesNoUnsure

Please provide further information in the box below, regarding the support needs of the person you are referring and how this impacts their ability to manage their housing related issues independently.*
Please note: This box must be filled as we need further information at this point in order to determine eligibility.

Are they currently receiving support from anyone else for any of the above?*
YesNoUnsure

Are they eligible for welfare benefits?*
YesNoUnsure

Do they have rent arrears?*

YesNoNot known

Section C: Safety

Are there any areas in Leeds the person does not feel safe to live in?*
YesNoUnsure

Would they feel safe in shared accommodation?*
YesNoUnsure

Have they recently been in hospital or A&E?*
YesNoUnsure

Have they been involved with the police or probation?*
YesNoUnsure

Have they experienced discrimination/harassment before (or currently)*
YesNoUnsure

Are there any pets in the property?*
YesNoNot known

Do they have any issues with drugs or alcohol?*
YesNoUnsure

Are they getting any help with this?*
YesNoN/A

If they are receiving help, who provides this support?

Is anyone else in control of or take any of their money?*
YesNoUnsure

Are they at risk by anyone?*
(i.e. Current/ex-partner, family, gangs, cuckooing)
YesNoUnsure

Have they ever received warning letters?*
(e.g. ASB, injunctions, harassment, orders, non-molestation orders, evictions)
YesNoUnsure

Has anyone made a Safeguarding referral for them before?*
YesNoUnsure

Are there any concerns/ history of self-harm or suicide?*
YesNoUnsure

Is there anything else you would like to add to help the person feel safe?

If accepted, the person you are referring may be provided with a visiting support-based service involving LONE WORKERS visiting them regularly at home or in public places. Do you consider that any additional precautions need to be taken when working with this person in these circumstances?*

Section D: Your Details

Would you like to be invited to the assessment?*
YesNo

First Name*

Last Name*

Organisation: *

Position: *

Your Address

Street Address

Street Address Line 2

City

Postcode (Required)

Phone Number (Mobile if Applicable) *

Email:*

Length of time you have known the person you are referring: *

Today's Date*