YMCA St Paul's Group Referral Form

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Personal Details
Funding responsibility agreed is for Commissioned services only. Choose Local Connection and select relevant connection and project if completing the form on behalf of a homeless applicant. Choose Self Referral if completing the form yourself.
If you do not have one, please enter N/A
If you do not have one, leave blank
Food allergies or dietary requirements
Timeline
A copy of the responses will be emailed to this address
Please include details of the local authority / charity / other professional organisation who is making this referral
Initial Assessment
Please provide a brief description of the main reasons why you are making this referral
Previous Accommodation
Self Assessment
At YMCA St Pauls Group, we use the Homeless Outcome Star to help identify residents support needs & track their progress on their journey to independent accommodation.

We would like you to provide as much information as possible about the 10 key areas which will form the basis of the residents support plan should they be successful in their application. 


Each area asks for a rating between 1 & 10. 1 is for high needs in this area & 10 is low support needs in this area.


1 & 2 – Stuck. Applicant requires support in an area but does not feel able to discuss the problem or accept help.

3 & 4 – Applicant accepts help in an area, but doesn’t consistently ask for assistance.

5 & 6 – Applicant believes they can make a difference in their life and starts to take some initiative towards positive changes.

7 & 8 – Applicant is growing in confidence & learning to take more responsibility for their goals and actions.

9 & 10 – Applicant requires little or no support in this area. 

(Check all that apply)
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If no proof of income is available, please provide statement or written evidence to confirm this



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