South Gloucestershire Intensive Support Service Referral Form

This service offers intensive supported accommodation for care leavers aged 18 – 25 in self-contained flats who will be assessed as ready to work towards a fixed-term tenancy using the Housing First model.

The keyworker will meet with the young person on a weekly basis to provide support with building day-to-day skills to support with independent living. This may include food shopping, budgeting, setting up utilities, paying bills, managing health care appointments, exploring hobbies and personal interests, and building a network in their community.

Once you have submitted the referral, a member of the Intensive Support Service will be in contact to discuss this further.

Due to the small size of our service, we are highly unlikely to be able to accommodate requests for a specific gender of worker.

Referrer Details

Name

First Last

Job Title & Organisation

Contact Number(s)

Referrers’ Manager

Manager Contact Details

Young Person's Details

Legal name (This is the name the young person is known as legally, either by birth or deed poll)

First Last

Preferred Pronouns

Date of birth

Age

Preferred language

Do they need a translator?

Yes

Are they literate in their language?

Yes

Current support received

Please include information about the young person’s level of engagement

Which services are they currently engaged in?

Agency

Lead Professional

Contact Details

Current EET status and goals

Current risks and concerns

Please briefly outline risk information, particularly relating to risks to staff - we will complete a full risk assessment and risk management plan when we meet with you

Previous historic risks or concerns (6+ months)

Does the young person have any known history of increased risk when working with a key worker of a specific gender?

Summary of Accommodation History

(Please include key events/reasons for moving/placement breakdowns)

The young person has given permission for our service to contact their accommodation service(Required)

Yes

Address of accommodation young person is living in at time of referral.

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone number of accommodation

Please let us know there are any areas of South Glos the young person needs to avoid

(If successful, we will need to supply the housing team with a list of areas the young person would be able to live)

Name of young person's support worker

First Last

Support worker's email address

Support worker's phone number

Assessment of Young Person’s Strengths and Concerns

How do you think YP would manage in a self-contained property?

Strengths

Concerns

Briefly describe what the current set up of their accommodation is, whether they have experienced living alone and how confident they are about navigating a new area of the city?

Personal and practical skills

Please give a brief description of the young person’s experience of managing their sleep routine, their typical days meals, any physical activity they enjoy and physical self-care.

Are there any physical or mental health support needs?

Please include any information about alcohol or drug use and sexual health.

Social relationships and networks

Please give a brief description of family relationships and friends

What interests/hobbies does the young person have?

Additional strengths and concerns that may be relevant to the referral

Equality and Diversity Information gathering:

1625 Independent People collects monitoring information about our applicants to make sure that a fair and equal service is provided to all. Any information will be in the form of total numbers or percentages and will not be linked to the young person.

Please describe the young person’s ethnic origin

Immigration status (if applicable)

Please tell us the young person’s country of origin

Year of first arrival in UK (if applicable)

What is their gender?

What is their gender identity?

Cisgender - where their gender identity matches the sex they were born (e.g., being born a man and identifying as a man) Transgender - where their gender identity does not match the sex they were born (e.g., being born a man but identifying as a woman)

Please tell us their sexual orientation

What is their religion

Please tell us if they have a disability

Yes

Did not wish to disclose

DATA PROTECTION

Independent people will use the information that you have provided in the referral form to help us make a decision about whether we are able to offer support to a young person.

We will not disclose the information in this referral to any other person or organisation, unless under a legal duty to do so, or if withholding information would pose a significant risk to the person being referred.

We take data protection seriously, to find out information about data protection, please read our Pr ivacy Notices, and our Privacy Notice for Young People is here.

We will explain the full details of our privacy notice, confidentiality and information-sharing policies if the referral is accepted. If you would like to find out more about how we will use the information contained in this referral, please contact the Intensive Support Services team using the information above.

The referral is able to be withdrawn at any stage and a request can be made that we do not use the information.