In order to consider and process your application, we need to ensure that, as much as possible, information can be shared between agencies about your needs. All information shared will be treated as confidential and shared only with those who need to know. See Data Protection Statement below.
I understand and agree that, in order for my application to be considered, it will be necessary for Next Steps Homes Ltd to have access to the information contained within this form. ☐
I also accept and agree that it may be necessary for Next Steps Homes Ltd to contact other agencies who work with me to get a better understanding of my individual needs. ☐
I confirm that the information on this form is correct and I understand that providing false information may lead to my application being declined or an offer of accommodation being withdrawn. ☐
I understand the services provided byNext Steps Homes Ltd, why I have been referred, and give my consent for a referral to be made. ☐
Signed (Applicant): | |
Print Name: | |
Date: |
Reason if applicant is unable to sign: |
Please note that if the statement of agreement is not signed by the applicant, Nissi Homes may not accept the referral. If someone is unable to sign, the referrer must provide valid reasons above.
We handle personal and sensitive information in accordance with the Data Protection Act 2018 and the UK General Data Protection Regulation (UK GDPR). Personal and sensitive information includes details provided by you or other organisations.
We will always manage information lawfully, including for statistical or research purposes and to maintain accurate records. We may share your information with organisations such as the police, medical professionals, probation services, or social services if they have a lawful basis to access it.
You have the right to:
Sensitive information provided to us in confidence by third parties will not be disclosed without proper justification.
For any information requests, administrative charges may apply where allowed by law.
SECTION 1: BASIC INFORMATION | |
Full Name: | |
Date of Birth: | |
Age: | |
Gender: | |
National Insurance No: | |
Current Address (Postcode): | |
Phone Number: | |
Nationality: | |
Spoken Language: | |
Language Barrier (if any): | Yes ☐ No ☐ Please give details below, if yes: |
Marital Status: | |
Ethnicity:
White – White British | Asian or Asian British - Indian | ||
White – White Irish | Asian or Asian British – Pakistani | ||
White – Any other White background | Asian or Asian British - Bangladeshi | ||
Mixed – White and Black Caribbean | Asian or Asian British – Others | ||
Mixed – White and Black African | Black or Black British -Caribbean | ||
Mixed – White and Asian | Black or black British - African | ||
Mixed – Any other Mixed background | Black or black British – any other black | ||
Other ethnic groups - Chinese | Asked but not disclosed | ||
Other ethnic groups – any other | Not asked |
Religious Belief:
Christian | Sikh | ||
Muslim | Other (please state) | ||
Hindu | None |
Sexual Orientation:
Lesbian | Bisexual | Asked but not disclosed | |||
Gay | Heterosexual | Not disclosed |
Dependants:
Do you have any children? | Yes ☐ No ☐ | |||
If Yes, How many? | ||||
Will any of the children be visiting or are you in contact with them? | ||||
Names of Children include sex & DOB | ||||
ny Social Services Involvement: If yes state why? | Yes☐ | |||
No☐ | ||||
Physical Description:
Height | |
Build | |
Weight | |
Facial Marks |
Other Contact Details:
Next of Kin: | |
Relationship: | |
Address: | |
Phone Number: | |
Mobile Number: |
Medical Contact Details:
GP Name: | |
Surgery Address: | |
Postcode: |
Social Worker
Name: | |
Phone No: | |
Email: |
Community Mental Health Teams (CMHTs)/ Child and Adolescent Mental Health Services CAMHS/ Care Co-ordinator (if any):
Name: | |
Phone No: | |
Email: |
Youth OffendingOfficer /Probation Officer / Offender Manager (if any):
Name: | |
Phone No: | |
Email: |
Drug Worker Contact Details (if any):
Name: | |
Phone No: | |
Email: |
Intervention Worker Contact Details (if any):
Name: | |
Phone No: | |
Email: |
Other Agency involvement:
Name: | |
Phone No: | |
Email: |
SECTION 2: REFERRAL AGENCY | |
Reasons for seeking supported accommodation: | |
Current Housing Situation: | |
Date Accommodation is required: | |
Have they lived in a Supported Accommodation in the past? | YES ☐ NO ☐ |
If yes, provide details (e.g., location, dates, any issues): | |
Any Rent Arrears: | Yes ☐ No ☐ |
If yes, provide details (amounts, creditors, etc.): | |
Please tick Referral agency from the table below
Social Services / Local Authority | Bail Hostel | ||
Probation | Health Services (Please specify below) | ||
OMU / Police | Voluntary Agency | ||
Prison (Please specify below) | GP Practice | ||
If other, please specify | |||
Referrer’s Details:
Name: | |
Organisation: | |
Organisation Address: | |
Phone Number: | |
Email: | |
Has the form been filled out on behalf of the applicant? | |
If yes, confirm that the applicant understands the support provided | |
Signature of referrer: (if completing electronical please type your first name) | |
Date: |
Previous Address History (Last 5 years)
Address | Period From (month & year) | Period To (month & year) | Type of Accommodation | |
1 | ||||
2 | ||||
3 | ||||
4 | ||||
5 |
SECTION 3: HEALTH NEEDS |
3A. Mental Health: | |
Any Mental Health illness? | YES ☐ NO ☐ |
If yes, please include diagnosis and details | |
Is there any history of suicide attempts or ideations, including self-harm? | |
If yes, please give details: | |
Do they currently feel that way? | YES ☐ NO ☐ |
When was the last episode? | |
Are they in receipt of any medication? If YES, please list the medication in section 3D | YES ☐ NO ☐ |
Is there mental health services involvement? | YES ☐ NO ☐ |
If NO, will one be required | YES ☐ NO ☐ |
3B. Physical Health or Disability: | |
Any physical health illness or disability? | YES ☐ NO ☐ |
If yes, please include diagnosis and details | |
Are they in receipt of any medication? If YES, please list the medication in section 3D | YES ☐ NO ☐ |
Do they have additional needs? | YES ☐ NO ☐ |
If yes, please include details | |
3C. Addictions: ALCOHOL MISUSE | |
Is there a history of Alcohol misuse? | YES ☐ NO ☐ |
if yes, for how long: | |
Are they still drinking currently? | YES ☐ NO ☐ |
If YES, state quantity: | |
If No, please state how long they have abstained: | |
Are they in receipt of any withdrawal medication? If YES, please list the medication in section 3D | YES ☐ NO ☐ |
Are they engaging with any services to manage this? | YES ☐ NO ☐ |
If YES, please provide contact details: | |
3C. Addictions: ILLICIT DRUG USE | |
Is there a history of drug misuse? | YES ☐ NO ☐ |
if yes, for how long: | |
Are they currently using illicit drugs? | YES ☐ NO ☐ |
If YES, state which drug and method of use: | |
If No, please state how long they have abstained: | |
Are they in receipt of any withdrawal medication? If YES, please list the medication in section 3D | YES ☐ NO ☐ |
Are they engaging with any services to manage this? | YES ☐ NO ☐ |
If YES, please provide contact details: | |
3D. Prescribed Medication: (Please inserted more rows if required or attach drug sheet if any.) | |||||
Medication | Dose | Dosage | Reason taken | Who manages this? | Active problem Y/N |
SECTION 4: RISK PROFILE |
Offending History Including current and previous. | |
Any Current Offence | YES ☐ NO ☐ |
Sentence Start & End Dates | FROM: TO: |
Are they on any Order or licence agreement such as youth offending/probation? Please give start and end dates | YES ☐ NO ☐ FROM: TO: |
Any Pending Court Cases? | YES ☐ NO ☐ |
If yes, please give details. | |