Current Accommodation Local authority general needs tenancy Housing association general needs tenancy Private sector tenancy Tied housing or rented with job Owner occupation (private) Owner occupation (low cost home ownership) Supported housing Direct access hostel Women’s refuge Foyer Housing for people Residential care home Hospital Prison Approved Probation Hostel Children’s home/foster care Bed and breakfast Short life housing Living with family Living with friends Mobile Home/Caravan Any other temp accommodation Home Office Asylum Support Rough sleeping Sofa Surfing Other (please specify) Significant History/Other: Training, Education, Employment and Income Income Full Time Wage Part Time Wage JSA / ESA DLA Pension OTHER Education/ Employment Paid Work Voluntary Work Full Time / Part Time Education Training No Education or Training or Employment OTHER Current income? £_______________ weekly/ fortnightly/ monthly Current debts? Housing Related Support Maximise income, including receipt of correct welfare benefits Reduce overall debt Obtain paid work Participate in training and/or education Participate in leisure /cultural / faith and /or informal learning activities Participate in work-like activities, (unpaid work/ experience /voluntary work) Establish contact with external services /groups /friends /family Developing confidence and ability to have greater choice and / or control and / or involvement Better manage physical health Better manage mental health Better manage substance misuse issues Assistive technology/aids and adaptations to help maintain independence Maintain and/or obtain accommodation and avoid eviction Comply with statutory orders /related processes in relation to offending behaviour Better manage self harm Avoid causing harm to others Minimise harm / risk of harm from others Substance Use - Past Alcohol Heroin Methadone/ Subutex Solvents Benzodiazipines Crack Powder Cocaine Amphetamine Ecstasy ‘Legal highs’ Cannabis Magic Mushrooms Ketamine Prescribed Medication Other Other details: Substance Use - Current
Health & safety risks whilst under the influence Housing Crisis Relapse Care Leaver Asylum Seeker Harm caused by visitors associates or cohabitants Any Has the client completed the self-assessment form? (NB: a self-assessment must be completed and returned to interview for accommodation referrals) Yes / No / NA Referrer Signature Print name Date Sheffield Visiting Support & Supported Housing - Referral Monitoring (protected characteristics) - Details DISC aims to promote equality and inclusion to ensure fair access to the service in line with the Equalities Act 2010. These questions are used to monitor access (as part of a yearly and ongoing review) to the service and are not used to make decisions on eligibility or allocation. DISC will not discriminate unlawfully and the below questions will help us to formally review access to the service and as such are an important part of how we protect the interest of those referred to our services. However, you do have the right to not answer any or all of the below but we would ask you then tick the box appropriate to your choice not to respond. DISC’s equality protocol is available on request. Marital Status Married/ Civil Partner Not Married/ Not Civil Partner (single) Cohabiting/ Domestic partnership Divorced/ Dissolved Civil partnership Widowed Other Client prefers not to state Not known – by client Not known – by referrer (only used if client not part of referral process) Pregnancy/ Maternity Status Pregnant In Maternity (post 26 weeks of birth) Not pregnant/ not in maternity Client prefers not to state Not known – by client Not known – by referrer (only used if client not part of referral process) Disability Status Disabled Not Disabled Other Client prefers not to state Not known – by client Not known – by referrer (only used if client not part of referral process) Ethnicity White British White Irish White Other Asian British - Indian Asian/ Asian British - Pakistani Asian/ Asian British - Bangladeshi Asian/ Asian British - Other Chinese/ Japanese Gypsy, Roma, Travveller Mixed – White and Black Caribbean Mixed – White and Black African Mixed – White and Asian Black or Black British – Caribbean or Black British – African Black or Black British – Other Other Ethnic Group Client prefers not to state Not known – by client Not – by referrer (only used if client not part of referral process) Faith / Religion Christian Muslim Other Atheist
Hindu Jewish Sikh Buddhist Agnostic Client prefers not to state Not known – by client Not known – by referrer (only used if client not part of referral process) Gender Male Female Transgender Gender Reassigned Other Client prefers not to state Not known – by client Not – by referrer (only used if client not part of referral process) Sexuality Heterosexual Homosexual Bisexual Client prefers not to Not known – by client Not – by referrer (only used if client not part of referral process)