Referral Form

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Food Bank

Home
Services
Referrals
- Referral Form
Report / Complaint
- REPORT A REPAIR
- Formal Complaint
News/Blog
Contact us
Careers
Food Bank

Home
Services
Referrals
- Referral Form
Report / Complaint
- REPORT A REPAIR
- Formal Complaint
News/Blog
Contact us
Careers
Food Bank

Contact us by filling out the form below.

Client Information

Referrer*

Contact Number*

Personal Details

Name of applicant*

Gender*

Male

Female

Date of birth*

N I number*

Phone number*

Email*

Country of origin*

Are you eligible for housing benefit?*

Yes

No

If you answered no, please give details:

Next of Kin name*

Next of Kin relationship and Contact details*

Current Housing Situation

Sleeping Rough*

Social housing*

Private rent*

Hostel*

Facing eviction*

Yes

No

Eviction date?

Sofa surfing*

Long stay Hospital*

Yes

No

Family home*

Prison*

Other(give details)

Where are you currently located – address/site/town*

Skills and qualifications – briefly tell us about your most recent job, your skills, what you enjoy doing and your ambitions for the future*

Five-Year Housing History

Start date 1*

End date 1*

Address 1*

Type of accommodation 1*

Reason for ending 1*

Start date 2*

End date 2*

Address 2*

Type of accommodation 2*

Reason for ending 2*

Start date 3*

End date 3*

Address 3*

Type of accommodation 3*

Reason for ending 3*

Start date 4*

End date 4*

Address 4*

Type of accommodation 4*

Reason for ending 4*

Start date 5

End date 5*

Address 5*

Type of accommodation 5*

Reason for ending 5*

Has the applicant ever lived in an Optimism Supported Housing?

OSH

From

To

Reason for leaving

Please give any other support workers/ organisations currently helping you with your accommodation needs

Support worker*

Organisation*

Address*

Phone number*

Phone number 2

Email*

Physical Health

Does the applicant have any physical health issues? If yes please give details below – include diagnosis, treatment and ability to self-medicate*

Does the applicant have any physical disability? If yes please give details below – include accessibility requirements*

Does the applicant have any allergies? If yes please give details below – including severity, treatment and ability to self-medicate.*

Does the applicant have any special dietary needs? If yes please give details below*

Please list any current medication below

Name of medication

Dosage

Side effects

Can the applicant climb stairs?*

Yes

No

Is the applicant fit enough to volunteer with OSH?

Yes

No

Mental Health

Does the applicant have any mental health issues?*

Yes

No

Please indicate the nature of these issues – tick any relevant boxes*

Depression

Schizophrenia

Alcohol abuse

Psychosis

Drug abuse

Self-harm

Anger problems/violence to self or others

Suicide attempts

Diagnosed personality disorder

Paranoia

Please give details of any known trigger(s) for episodes of the above*

Please give details of any mental health services applicant is engaged with*

Service*

Phone number*

Address*

Drug Use

Please tick any drug/substance that you have used recreationally*

Cannabis – any form

Mephedrone

Cocaine

Heroin

LSD

Ecstasy or other MDMA variant

Amphetamines

Ketamine

NPS ‘Legal Highs’

I never used any drugs

Please tick any drug/substance that you have used regularly

Drug*

Cannabis

Cocaine

Crack

Heroin

LSD

Ecstasy, MDMA or other variant

Amphetamines

Ketamine

Mephedrone

Magic Mushrooms

NPS ‘Legal Highs’

Other

Age started*

16-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65+

Length and frequency of use*

Length of time clean*

Previous treatment for drug use

Treatment received

Agency

From*

To*

Current treatment for drug use

Treatment received

Agency

From*

To*

Any known triggers for drug use or relapse?*

Optimism Supported Housing expects people who have a history of alcohol abuse to be prepared to address this problem and will work with them to do so.

Alcohol Use

How many units of alcohol do you drink?*

Daily

Approx. units

Weekly

Approx. units

Monthly

Approx. units

Rarely

Tick if you only drink rarely

What alcohol do you drink?

Has alcohol ever caused any of the following problems in your life?*

Relationship breakdown

Victim of violence

Debt

Aggression

Eviction

Hospital admission

Loss of job

Cirrhosis

Offending

Pancreatitis

Other – please specify

Have you ever sought or been advised to seek help for alcohol abuse?*

Yes

No

Previous treatment for alcohol use

Treatment received

Agency

From

To

Current treatment for alcohol use

Treatment received

Agency

From

To

Do you have any triggers for binge drinking / excessive alcohol use? – please give details below*

Do you have a family history of alcohol abuse? – if yes please give details below*

Optimism Supported Housing expects people who have a history of alcohol abuse to be prepared to address this problem and will work with them to do so.

Gambling History

Have you gambled in the past?*

Yes

No

If yes please give details below

Do you receive any help/support to abstain from gambling?*

Yes

No

Who by?

Has gambling ever caused any of the following problems in your life?*

Relationship breakdown

Victim of violence

Debt

Offending

Eviction

Mental health problems

Loss of job

Other – please specify

Offending History

Criminal convictions*

Yes

No

If yes please give details

Probation orders*

Yes

No

If yes please give details including Probation office and named office

Outstanding court appearances / warrants*

Yes

No

If yes please give details

Cautions – if yes please give details*

Yes

No

Cautions – if yes please give details

Arson ( that may or may not have resulted in a criminal conviction)*

Yes

No

Arson if yes please give details

Violence (that may or may not have resulted in a criminal conviction)*

Yes

No

if yes please give details

Sexual offences/ named on Sex Offenders Register – if yes please give details*

Yes

No

If yes please give details

Financial History

Assets / savings*

Do you have bank account?*

Yes

No

If 'yes' Bank Account

Debts*

Amount owed*

For what*

To whom*

Since year*

Confidentiality

Optimism Supported Housing respects your confidentiality, any information provided will only be used to assist in the risk assessment, needs assessment and selection process needed to comply with our admission policy, a copy of which is available on request. This information will be kept secure and only for as long as needed and not be seen by anyone who is not involved in the above process.

I agree that the information provided is true and correct. I acknowledge that by giving information which I know to be false I may be at risk of my licence to occupy being withdrawn.*

Signature of applicant*

Date*

Referees

Name 1*

Relationship 1*

Contact details – please include mobile and office numbers, email and business address*

Name 2*

Relationship 2*

Contact details – please include mobile and office numbers, email and business address*

Consent Disclosure

If your referral is being returned via email please note that once this section has been completed, pages 8 and 9 should be printed, signed, scanned and returned with the completed referral. Please retain the original, should it be required in the future.

Date*

Name*

NI number*

I give my permission to disclose my information to Optimism Supported Housing*

I give my consent under the Data Protection Act 1998 for Optimism Supported Housing
to contact any relevant agencies regarding myself in the best interests of myself and the Optimism Supported Housing.

Sign: (Applicant)*

Sign: (On behalf of Referral Agency)*

Please send your completed application form to or by email to:

info@Optimismsupportedhousing.co.uk

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