Get Referral Form - My Space Housing Solutions

We should think about what we want to achieve in the way of future outcomes and how we might want this person to access their community in the future Location Amenities Community Links Transport Links Brief Risk Assessment Risk to Self Risk to others staff neighbours Risk to Property Has there ever been evidence of arson If so please give more information Other recorded events of significance relating to tenancy/properties Additional Information include here any drug or alcohol dependency or abuse that will have an effect on a tenancy other known individuals that associate with the Client that may have an effect on the tenant Name of person completing this form Signature Designation Please send back to 111 Sand Aire House Stramongate Kendal Cumbria LA9 4UA info my-spacehousing.co. Referral Form This form needs to be completed by the appropriate professional person who is making this referral. eg Doctor CPN Social Worker Care Coordinator etc. When completed this form please can you give as much information as possible this will help us process the application quicker. Please attach previous care plans and risk assessments Yes No Please complete the additional information form Date Contact Tel NINO Tenant Name Team Email Date of Birth Are you requesting My Space to provide supported accommodation for this individual This means that the individual needs regular ongoing housing related support from us as a landlord that is over and above that needed in an unsupported tenancy and separate to any other support or care arrangements If the answer to this question is No then our service is possibly not appropriate and you should seek housing from General Landlords If Yes Briefly outline the housing related supported that the individual will need to enable them to manage their tenancy successfully MY SPACE Housing Solutions- Incorporation Number 0825705 Registered Charity Number 1149955 Briefly explain the reasons why the tenant is not able to be provided with accommodation by Local Authority Housing Association or Private Landlord Would the tenant be classed as a vulnerable person In what way is the tenant vulnerable Is the tenant in receipt of / or qualifies for DLA or incapacity benefit Medical Condition Diagnosis symptoms etc Legal Status if any e.g. section 25 117 forensic or other Other Relevant Agencies involved in care Brief Social History events that led to intervention homelessness Client Support Needs with Accommodation e.g. home economics Appointee ship maintenance of tenancy etc Property Specifications Date accommodation needed by. Please attach previous care plans and risk assessments Yes No Please complete the additional information form Date Contact Tel NINO Tenant Name Team Email Date of Birth Are you requesting My Space to provide supported accommodation for this individual This means that the individual needs regular ongoing housing related support from us as a landlord that is over and above that needed in an unsupported tenancy and separate to any other support or care arrangements If the answer to this question is No then our service is possibly not appropriate and you should seek housing from General Landlords If Yes Briefly outline the housing related supported that the individual will need to enable them to manage their tenancy successfully MY SPACE Housing Solutions- Incorporation Number 0825705 Registered Charity Number 1149955 Briefly explain the reasons why the tenant is not able to be provided with accommodation by Local Authority Housing Association or Private Landlord Would the tenant be classed as a vulnerable person In what way is the tenant vulnerable Is the tenant in receipt of / or qualifies for DLA or incapacity benefit Medical Condition Diagnosis symptoms etc Legal Status if any e.g. section 25 117 forensic or other Other Relevant Agencies involved in care Brief Social History events that led to intervention homelessness Client Support Needs with Accommodation e.g. home economics Appointee ship maintenance of tenancy etc Property Specifications Date accommodation needed by. This must be a date between 14 and 90 days of this referral date Please inform us of current accommodation and notice required and reasons why they are leaving Type of accommodation needed House Please tick all possible options Flat / Apartment End Terrace Single Storey Detached Mid Terrace Ground Floor Semi Detached Details of each room as applicable Including minimum numbers required size of rooms equipment adaptations etc Bedrooms Bathroom s Kitchen Garden Parking Special Requirements/adaptations to property due to specific disability Local area please detail what the service user s needs are and also anything they would not want. Uk Tel 01539 737569 ADDITIONAL INFORMATION National Insurance No Previous address Have they previously claimed housing benefit if so when What benefits are they getting How much When did they start getting it Are they waiting to hear about any benefits When did they claim Bank Account details/ Post office account How much do they have in their account Any other savings income stock shares ISA property Any pensions.