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Page 1

East Sussex Floating Support Service: Referral Form

The information needed to complete this form includes:

Client's name and contact details
Client's date of birth
The reason for referring the client - Please take the time to provide as much pertinent information as you can as it will help the service respond more promptly and accurately to the referral
Risk details regarding the client
Safeguarding information
Client's equalities information
Referrer's details

Please note that data entry is limited to 1250 characters per field

Referral Date

Client's Title

Client's First Name

Client's Last Name

Client's Birthdate

Client's Preferred Name

Reason for Referral

N.B. This field is limited to 1250 characters

Housing Options, Resettlement and Tenancy

N.B. This field is limited to 1250 characters

Income Management, Benefits and Employment

N.B. This field is limited to 1250 characters

Vulnerability, Health and Wellbeing

N.B. This field is limited to 1250 characters

Client's Gender

Client's Landline

Client's Mobile Phone

Client's Email

If email address is not known, please leave blank

Client's NI number

Please use format: 2 uppercase letters, then any 6 numbers, then one uppercase letter A-D. (No spaces.) - Leave completely blank if NI number unknown

Client's Address

Street (Including House, Building or Flat Number/Name)

City

County

Post Code

Recommended Visiting Arrangements - Visit Safety

N.B. This field is limited to 1250 characters

Visiting Arrangements

N.B. This field is limited to 1250 characters

How Should We Contact the Client?

To select more than one option, hold down the CTRL key on your keyboard before clicking on the relevant options.

Secondary Contact

Emergency Contact's Name

Emergency Contact's Number

Emergency Contact's Relationship?

Are There Any Communication Needs?

N.B. This field is limited to 1250 characters

Translator required

Preferred language

Large Print Needed

Registered with a GP?

NHS number

Adult Social Care Number

Referrer's Name

If this is a self-referral, please enter your own name

Referrer's Phone Number

Referrer's Email

Referrer's Relationship to Client

Referral Agency Name

If this referral is for yourself, a relative or a friend, please enter "N/A"

Referral Agency Department

If this is not applicable, please enter "N/A"

Referrer's Address

Referral Address Formula Field, Hidden

Referrer Would Like to be Kept Updated as to Support Outcomes

YesTick if you would like to be kept updated

Is it safe for the client to receive phone calls, text messages and/or e-mails?

To select more than one option, hold down the CTRL key on your keyboard before clicking on the relevant options.

Can the client speak freely?

Are there any issues with the misuse of alcohol or substances within the household?

Is there any history of violence or aggression from anyone in the household?

Is the client a Risk to themselves?

Is any adult within the household at risk of abuse or neglect?

Are there any risks facing the children in the family?

Is there any current safety plan or Child Protection plan in place?

Risks To Client - Comments

If the answers to any of the above risk questions is "yes", please add further details here. - N.B. This field is limited to 1250 characters

Does the client have any weapons?

Does the client have a criminal record and/or is the client known to the police /probation service?

Has the client been assessed as high risk under a MAPPA?

Has the client been assessed as high risk under a MARAC?

Risks From Client - Comments

If the answers to any of the above risk questions is "yes", please add further details here. - N.B. This field is limited to 1250 characters

Environmental Risks - Comments

N.B. This field is limited to 1250 characters

Household Type – Family Composition

Number of People in Household

Page 2

Case Currently Open To

Primary Support Need

Third Party Name

Third Party Phone

Third Party Email

If email address is not known, please leave blank

Name of Third Party Service/Team

Housing Situation at Referral

No Accommodation

Resettlement Support

Losing/At Risk of Losing Accommodation

To select more than one option, hold down the CTRL key on your keyboard before clicking on the relevant options.

Unsuitable Accommodation

Issues Managing Accommodation

To select more than one option, hold down the CTRL key on your keyboard before clicking on the relevant options.

Referred Under Duty to Refer Protocol

When Will Referral Be Made?

Services Currently Working With

N.B. This field is limited to 1250 characters

Safeguarding

N.B. This field is limited to 1250 characters

Subject to MAPPA

N.B. This field is limited to 1250 characters

Case Recently/Due To Be Discussed at MARAC

N.B. This field is limited to 1250 characters

Page 3

Disabled person

Disability type(s)

To select more than one option, hold down the CTRL key on your keyboard before clicking on the relevant options.

Wheelchair user

Ethnic origin

Ethnic Other

Sexual orientation

Sexual Orientation Other

Religion

Religion Other

Gender Identity

Transgender

Economic Status

Is the Client a Carer?

Care leaver

Armed Forces History

British Armed Forces

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