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

Young Person's Details

Legal name (This is the name the young person is known as legally, either by birth or deed poll)
DD slash MM slash YYYY
Do they need a translator?
Are they literate in their language?
Please include information about the young person’s level of engagement
Which services are they currently engaged in?
Agency
Lead Professional
Contact Details
 
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
(Please include key events/reasons for moving/placement breakdowns)
The young person has given permission for our service to contact their accommodation service(Required)
Address of accommodation young person is living in at time of referral.
(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

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?
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.
Please include any information about alcohol or drug use and sexual health.
Please give a brief description of family relationships and friends

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.
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 if they have a disability

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 Privacy 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.