REFERRAL FORM

Please note that incomplete or inappropriate referrals may be returned to the referrer.

One YMCA is a Registered Company No: 4430743. Charity No: 1102301. RSH No:H4418.

Email: referrals@havenfirst.org.uk

Referral details

Please indicate which site this referral is for:

StevenageNorth Herts

Referral Organisation:

Organisation type:

Contact: First name:

Last name:

Address:

Town:

Postcode:

Telephone number:

Email:

Applicant information:

Title:

Gender:

First name:

Last name:

Date of birth

Is NI number known?

NI Number:

Telephone:

Email: (please only enter valid email address or leave blank if not known)

Preferred method of contact:

EmailTelephone

Last address or c/o address:

Address:

Town:

Postcode:

Next of kin/emergency contact:

First name:

Last name:

Telephone:

Relationship:

Relationship type:

Suitable to contact?

Source of referral?

What is the reason for the referral?

Please give brief details:

What is the main cause of homelessness?:

How long have you been homeless?

Current housing situation:

Do you have a local Hertfordshire connection?

Borough at point of referral:

Family history and details of any local connection (what family do you have and where do they live):

Previous housing history (for last 10 years, also including periods of rough sleeping if any). Please start with most recent address:

Address:

Town:

Postcode:

Date from

Date to (must not be the same as the date from)

In what capacity did you live there? Private tenant/council tenant/with friends, etc.

Name of landlord:

Address of landlord:

Reason for leaving:

Offending history:

Do you have any previous convictions/arrests (including NFAs)?

Please list convictions:

Do you have a history of violence (verbal or physical)?

Please provide details of violence:

Are you currently on bail/tag or awaiting court date?

Please give bail address and details of offence:

Do you have any convictions for arson?:

Details of arson conviction(s):

Have you ever been on the sex offenders register?:

Details of being on sex offenders register:

Are you currently on a supervision or probation order?:

Details of current supervision or probation order:

Have you previously had a supervision or probation order?:

Details of previous supervision or probation order:

Health; please indicate whether the client has or has had any of the following:

Physical health problems:

Details:

Substance/alcohol misuse:

Details:

Mental health:

Details:

Medication:

Details:

To be completed by referral agency: Mini risk assessment.

Has the client shown any current or previous aggressive, threatening or abusive behaviour to others or staff?

Details:

Are there any known issues for the client when working alone with staff?

Details:

Is there any suspicion of theft from previous accommodation?

Details:

PERSONAL DATA PROCESSING CONSENT FORM

The General Data Protection Regulations (GDPR) stipulate that all client data should be collected for a specific purpose, used only for that purpose and only retained if it continues to meet that purpose.

The type of personal data we will collect and process on you as a client may vary from time to time, but it will always relate to your application and further processing of your support contract.

At all times, your personal data will be treated as strictly confidential.

The purpose of this form is for you to acknowledge and accept that One YMCA holds personal data about you and to request your consent to the processing by the Charity.

Consent is not defined in the Data Protection Act. However, the European Data Protection Directive (to which the Act gives effect) defines an individual’s consent as:

…any freely given specific and informed indication of their wishes by which the data subject signifies their agreement to personal data relating to them being processed.

I have read and understood this Consent Form. I understand that by signing this form, I explicitly consent to One YMCA processing any sensitive personal data relating to me, including but not limited to my medical reports, details of spent and unspent criminal convictions and Equality Monitoring data. I understand that One YMCA needs to process this data as necessary for the performance of my License Agreement.

Further, I consent to the Organisation providing my personal data to a third party where this is necessary for the processing of my housing application and further processing of my support contract.

Your data will not be shared with any third parties outside the EU without further consent.

I understand that my consent can be withdrawn or the processing of my data restricted and that I have the right to access the data the Organisation holds about me; rectify the data if inaccurate; erase the data (unless the Organisation has a lawful reason for processing or storing the data); port the data in order to share my data with another Organisation (for example the Council). Further information, including the privacy policy can be found on our website-www.oneymca.org. You can also write to the Data Protection lead at One YMCA.

Does the client give consent?

I give my consent

Full name:

Date

PERSONAL DATA PROCESSING CONSENT FORM

EQUAL OPPORTUNITIES MONITORING FORM