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Inspiring Communities, Nurturing Success
Inspiring Communities, Nurturing Success
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MAKE A REFERRAL
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HOME
ABOUT US
OUR SERVICES
Accommodation
MAKE A REFERRAL
Inspiring NEWS
CONTACT US
Referral Form
Referring Authority/Agents Details:
Referrer’s Name
Referer Organisation
Referer Contact Phone Number
Referer Email
Referer Address
Details of involvement with the applicant:
Applicants/Beneficiaries Details
First Name
Surname
Date of birth
Age
Gender
Marital Status
Ethnicity
Country of Origin
Current Address
Type of current accommodation
Length of time at current address
Contact Phone Number
Legal Status (if applicable)
Refugee
Asylum Seeker
Bio-Metric Data Card Held
Yes
No
Disability needs
Reasons for making a referral to this organisation
Transition Assessment/ Care/Support plan already in place
Yes
No
If 'yes' Please upload a copy
What would the referrer and applicant agree are the main areas of support needed whilst living at one of our homes
What would the applicant like to achieve from living at one of our homes
Please indicate the expected duration of placement (between 6 months to 2 years)
Housing History
Has the beneficiary ever been evicted
Yes
No
Has a Housing Application form been completed
Yes
No
Please give a detailed housing history including any periods of homelessness
Risk Assessment
Conviction of Arson
High
Medium
Low
N/A
Physical aggression to others
High
Medium
Low
N/A
Verbal aggression
High
Medium
Low
N/A
Damage to property
High
Medium
Low
N/A
Alcohol Abuse
High
Medium
Low
N/A
Drug/Substance Misuse
High
Medium
Low
N/A
Sexual Behaviour (risk to others)
High
Medium
Low
N/A
Self Harm
High
Medium
Low
N/A
Criminal behaviour
High
Medium
Low
N/A
Sleep disturbance/nocturnal difficulties
High
Medium
Low
N/A
Mental Health i.e ongoing historical or significant emotional health issues
High
Medium
Low
N/A
Please indicate any other Risk Factors
Guidance, Advice & Support required
Please indicate the level of support the beneficiary will require in each of the areas.
Budgeting /Paying bills
High
Medium
Low
N/A
Accessing benefits
High
Medium
Low
N/A
Mental Psychological /Emotional Health
High
Medium
Low
N/A
Personal hygiene
High
Medium
Low
N/A
Health & safety in the home
High
Medium
Low
N/A
Escorting
High
Medium
Low
N/A
Accessing social & recreational activities
High
Medium
Low
N/A
ESOL - Language or literacy
High
Medium
Low
N/A
Access to education & employment
High
Medium
Low
N/A
Digital Training – PC/computer Literacy
High
Medium
Low
N/A
Behaviour/Anger Management
High
Medium
Low
N/A
Registering with GP
High
Medium
Low
N/A
Physical health care problems
High
Medium
Low
N/A
Nutrition/ weight
High
Medium
Low
N/A
Family mediation
High
Medium
Low
N/A
Peer mediation
High
Medium
Low
N/A
Vulnerable exploitation
High
Medium
Low
N/A
Mobility
High
Medium
Low
N/A
Religious/cultural
High
Medium
Low
N/A
Medication/prescription
High
Medium
Low
N/A
Please indicate if there is any other assistance required
Contact details of other agencies involved in the clients’ care or supervision
Agency 1
Name of Agency
Name of Agency Contact
Phone Number of Agency Contact
Address of Agency
Agency 2
Name of Agency
Name of Agency Contact
Phone Number of Agency Contact
Address of Agency
Agency 3
Name of Agency
Name of Agency Contact
Phone Number of Agency Contact
Address of Agency
Information Processing Statement
Dazzling Futures Services CIC commits to holding your data securely and treating it with sensitivity in accordance with the European General Data Protection Regulation 2018 and the UK Data Protection Act 2018 and amends. We will use the details you’ve supplied to help us determine appropriateness of placement within our accommodation, share information about our services and respond to questions. As part of our ESG policy to preserve the environment, we send most of information by email.
However, important notices and information may be sent by post. Data is not disclosed to external organisations other than internal vetted personnel or government authorities with whom Dazzling Futures Services has authorised Data-Sharing arrangements. You have the right to object to the use of your details for any activity at any time. Your data will be destroyed if we do not offer our accommodation services to you. If you’d like to find out more about how we process your details, please refer to our Privacy Policy on our website.
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