Are you in receipt of any benefits or income? (weekly, fortnightly, monthly) Income Support £…………. W/F/M ESA £…………. W/F/M JSA £…………. W/F/M DLA £…………. W/F/M Pension £…………. W/F/M Housing Benefit £…………. W/F/M Other £…………. W/F/M Location of Benefits Office Date of Last Payment Priority Debt Outstanding to: Amount: £…………… Paid into: Post Office Bank Account Other Non- Priority Debt Outstanding to: Amount: £…………… Do you have any difficulties relating to money management? SECTION TWO – HOUSING SITUATION What is the Service User’s current housing situation? Please select from the options below; Sofa surfing – with friends or relatives Rough Sleeping Problems with current accommodation e.g. disrepair, rent issues Threatened with homelessness e.g. asked to leave home, notice served by landlord Housing Association Tenant Local Authority tenant Living in supported accommodation Living in emergency accommodation e.g. hostel/refuge Private rented tenant Owner occupier Leaving prison (detail date of release) Leaving Hospital /residential care (detail discharge date) Temporary accommodation provided by LA Living in approved premises (Bail Hostel) Fleeing violence/safety issues Other (Please elaborate) Registered with the NIHE YES NO Accommodation History (Last Five Years if Possible) Date from Date to Type & Location of Accommodation Reason for Leaving i.e. eviction, family breakdown, discharge etc SECTION THREE – SUPPORT REQUIRED Please indicate below if what level of support the applicant would require in the following areas; LOW MEDIUM HIGH Developing budgeting skills Managing debt Support to access/claim welfare benefits Developing skills to complete Developing skills to undertake domestic/household tasks Basic skills (numeracry/literacy) Accessing further education Opportunities for paid employment Accessing community, social, leisure activities Accessing faith and cultural networks
undergoing a detox programme? timescales, agency involvement etc); LEGAL SITUATION Has the Service User ever been convicted of a serious violent offence? YES NO If YES please provide further details; Has the Service User ever been convicted of an Arson offence? YES NO If YES please provide further details; Has the Service User ever been convicted of a sexual offence? YES NO If YES please provide further details; Any warrants outstanding? YES NO If YES please provide further details; Is the Service User on Bail, Supervision Order or due to appear in court? YES NO If YES bail conditions MUST be attached; Is the Service User registered with probation? YES NO If YES please provide further details (name of probation officer); Can you provide details of any current or outstanding charges or sentences you are serving, be sure to include dates of outstanding cases or release etc. Prison Number (if applicable) Release Date (if applicable) SECTION 4 – RISK ASSESSMENT When completing this please consider whether any risk applies to the service user, others and from others. LOW: Minimal MEDIUM: Significant but Stable HIGH: Significant & Volatile Risk of Harm to Others (Violence & Abuse) Yes No LOW MEDIUM HIGH FURTHER COMMENT (inc known triggers) 1.Current behaviour/demeanour is threatening or abusive 2. Previous incidents of violence or physical aggression 3. Expressing intent to harm others 4. Evidence of intent to harm others (e.g. keeps weapons) 5. Poor engagement with services and/or concern expressed by others 6. Poor engagement with care/support plan 7. History of drug/alcohol misuse Risk of Harm to Others (Violence & Abuse) Yes No LOW MEDIUM HIGH FURTHER COMMENT (inc known triggers) 8. Custodial sentences or arrest for violent behaviour 9. Previous history of abusing others 10.Close associates known to be aggressive