SUPPORTING PEOPLE REFERRAL FORM Please complete this form if you are interested in receiving support to help you successfully manage yourhome or you would like to be considered for supported housing and sign the form. If you are completingthis form on behalf of someone else please discuss the referral with them and ensure that they agree toreceive support and sharing the information. If you are unable to get the form signed please ensure verbalconsent is given and note this in in the signature box at the end of this form before returning it.

How we use your personal data: The information in this form is required to help us understand yourindividual needs and how best we can support you by referring you to the most appropriate provider. If youwould like to know more about how the Supporting People Team processes your personal data, please visitour service privacy notice on the Council’s Data Protection pages at www.rctcbc.gov.uk/dataprotection or aska member of staff.

Which language would you like us to communicate with you?

Welsh � English � Bilingually �

What type of housing support do you need?

I need support to help me in my current home �

I need support to move into my new home �

I need a project with 24 / 7 support (This may be shared accommodation) �

I don’t need 24 hour support (This may be shared accommodation) �

1. If you are applying for Supported Housing, where would you like to be placed: (you may wish to referto the Supporting People Directory of Services to help you decide on the project which bests meetsyour needs).

Rhondda � Cynon � Taf � No Preference �

2. Have you previously received support service from Supporting People?

YES� NO�

Can you tell us who with

________________________________________________________________________________________

Name

________________________________________________________________________________________

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3. About You

First name(s): ____________________________________________________________________________

Surname: ________________________________________________________________________________

Date of Birth: ____________________________________________________________________________

National Insurance Number: ________________________________________________________________

Current Address: __________________________________________________________________________

________________________________________________________________________________________

Postcode: ______________ Contact Telephone Number: ______________________________________

Is it safe to contact you or to leave a message? YES � NO �

Are you able to access the internet? YES � NO �

Email Address: ____________________________________________________________________________

Gender: ________________________________ Marital Status: ____________________________________

Ethnic Origin: ____________________________ Nationality: ______________________________________

Please provide details of any religious or other beliefs? : ______________________________________

Do you consider yourself disabled? YES � NO �

If yes, please give details : __________________________________________________________________

Do you have any specific health problems or difficulties? YES � NO �

Please describe: __________________________________________________________________________

Do you have any communication needs you would like us to consider? (Please Tick)

Hearing Impairment � Speech impairment � Visual impairment � Physical impairment �

Other please give details: __________________________________________________________________

If we are unable to contact you, who would you like us to contact on your behalf?

Name: __________________________________________________________________________________

Contact Telephone Number: __________________________________________

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4. Our current housing situation and support needs.

If you are moving into a new property, what date are you moving in? ________________________________

What is your new address? __________________________________________________________________

Landlord Details

Name: __________________________________________________________________________________

Contact details: __________________________________________________________________________

Please Tick Please give details e.g. how long lived there

An Owner Occupier

Renting from a HousingAssociation

Renting from a private landlord

Living with family or friends

Living in temporaryaccommodation/B&B/Hostel

Rough Sleeping

I am moving into my new home.

Living in a caravan/mobile Home

Other, please provide details?

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5. In relation to your current circumstances

Please Tick Please give details

Are you employed?

Are you retired?

Are you a student?

Are you on training course?

Do you volunteer?

Do you receive any benefits?

6. What is the main reason why you need support (lead need?)Please indicate at least one box. If you have more than one reason, please order in priority (1-5)

Domestic Abuse (E1)Homelessness or need to prevent homelessness(E10)No: No:

Learning Disabilities (E2) Chronic Illnesses (including HIV, Aids) (E11)No: No:

Mental Health Issues (E3) Single Parent with Support Needs (E12)No: No:

Alcohol Issues (E4) Over 50 years of age with Support Needs (E14)No: No:

Substance Misuse Issues (E5) Family with Support Needs (E16)No: No:

Refugee Status (E6) Young person who are Care Leavers (E17)No: No:

Physical and/or Sensory Disabilities(E7) (E15)

Someone with Developmental Disorders(i.e. Autism) (E19)No: No:

Young person with SupportNeeds (16 to 24) (E8)

Single person with Support Needs not listedabove (25 to 54) (E21)No: No:

Criminal Offending History (E9)No:

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7. What support networks do you have?

Are you currently receiving support or help from any professionals or friend or family member?

such as a social worker, nurse, CPN, Probation Officer, housing officer, carer?

If so, please provide their details.

Who:____________________________________________________________________________________

Name: __________________________________________________________________________________

Tel: ____________________________________________________________________________________

Who:____________________________________________________________________________________

Name: __________________________________________________________________________________

Tel: ____________________________________________________________________________________

8. Have you previously received support from any professionals such as a social worker, nurse, CPN,probation officer, housing officer, carer If so please can you let us have the details

Who:____________________________________________________________________________________

Name: __________________________________________________________________________________

Tel: ____________________________________________________________________________________

Who:____________________________________________________________________________________

Name: __________________________________________________________________________________

Tel: ____________________________________________________________________________________

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9. What support do you feel that you need help with?

Please Tick Please give details

Do you need help to manageyour money to include payingyour rent or other bills, applyingfor benefits including UniversalCredit or Housing Benefit or helpto manage any debt/s

Do you need help to fill in formsor reading and dealing with yourletters and bills?

Do you need help with lookingfor work, training, volunteering orwith going to activities in yourlocal area

Do you need help with lookingafter yourself including makingappointments or visiting a GP ordentist or other medicalprofessional or eating healthily orhelp with your mental well-being.

Do you need help to move andlook for alternative accommodationor help to apply to Homefinder orto bid for properties

Do you need help to feel safe inyour home e.g. help with gettingadaptations to your home easier tolive in such as having a shower andgrab rails fitted, fire safety measures,

Do you need help to manageand maintain your home e.g.arranging repairs, looking afteryour garden, helping to keep theproperty clean and tidy

Do you need any help to preventthe loss of your home such asantisocial behaviour, substancemisuse, medical or social needs?

10. Please can you tell us about your current circumstances to help us Identify if you need ourimmediate help?

Please Tick Please give details

Are you at risk of losing yourcurrent accommodation toinclude anti-social behaviour,substance misuse or mentalhealth issuesDo you have rent or mortgagearrears? If yes, how much and doyou have an arrangement in placeto reduce the arrears?

Are you subject to any legalaction i.e. NTQ ,Eviction date orpossession order

Have your benefits beenstopped or sanctioned toinclude Housing Benefit andUniversal Credit

Do you have accommodation butare unable to live in it /return to it?

Do you have accommodation, butfinding it difficult to manage.

Are you currently in prison? Do you have a release date? What are your bail conditions?

Are you currently in hospital?Do you have a date fordischarge?

Have you been in care?

Are you currently serving orpreviously served in the armedforces?

Are you experiencing harassmentor at risk of violence from others?

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11. Do you have any other information you think would be useful for us to know in order that we cansupport you effectively?

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12. If you are making this referral on behalf of someone please ensure they want support and theysign this form.

Referrer’s Name: __________________________________________________________________________

Organisation If applicable and Postal address: __________________________________________________

Contact Telephone Number: ________________________________________________________________

Email Address: ____________________________________________________________________________

What is your relationship to the applicant? ______________________________________________________

If you are completing the form on behalf so someone else, please discuss the referral with them and ensurethat they give consent to be referred for support.

If you are a referring agency completing this form on behalf of someone you are currently providinga service to, please attach additional information e.g. risk assessment.

Has the applicant consented to this referral? YES� NO�

Sharing my information

I understand that in order to receive support, the information recorded on this referral form will be shared withthe most appropriate agency or organisation that may be able to meet my needs through the provision ofadvice and support.

Name: __________________________________________________________________________________

Signature: ___________________________________ (If unable to obtain a signature please notify us verbally)

Date:____________________________________________________________________________________

PLEASE RETURN THE FORM TO RHONDDA CYNON TAF COUNTY BOROUGH COUNCILSUPPORTING PEOPLE TEAMSARDIS HOUSE, SARDIS ROAD,PONTYPRIDDCF37 1DU

Tel: 01443 281482

Email: SupportingPeopleteam@rhondda-cynon-taff.gov.uk

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