Name *
Date of Birth *
Gender *
Nationality *
Address *
Primary Language *
Phone *
Email *
Current Living Situation *
Contact Name *
Contact Phone *
How Did You Hear About Us? *
Name *
Organisation *
Email *
Communication Method *
Mobility
Personal Care
Medication
Communication
Road Safety
Accessing The Community
Behaviour Support
Restrictive Practices
Social Activities
Please provide information about the level & type of support you/ person being referred require to manage daily living skills:
What are your/ person being referred’s current goals around developing Independent Living Skills?
What are your/ person being referred’s current strengths and abilities regarding Independent Living skills?
Which areas do you/ person being referred currently require the most support with?
Which areas do you/ person being referred currently require the most support with?
Please detail how you/ person being referred communicates most effectively, list any communication tools/ aids/ techniques:
How can we best support you/ person being referred to communicate effectively?
Please describe your/ person being referred’s literacy & numeracy skills:
How do you/ person being referred process information, remember things, learn and understand?
Please tell us about your/ person being referred’s interests, strengths, favourite topics etc
Explain how you/ person being referred stays safe and the level of support required to be safe both at home and in the community. Include info about vulnerability, understanding of potential hazards around the home, road safety etc.
Are there any sensory differences that you/ person being referred may seek out or avoid?
How can we best support you/ person being referred with sensory needs?
Do you/ person being referred require support with social interactions, making & keeping natural friendships, understanding social cues, resolving conflict etc?
Do you/ person being referred have friends/ family and a circle of support? Please give a brief overview:
Please give an overview of your current emotional wellbeing:
Do you/ person being referred have a mental health care plan or positive behaviour support plan in place?
How can we best support you/ person being referred to maintain stability with you emotional wellbeing?
Are there any risks relating to self/ others/ property that we should have information about? (Please provide information about potential self-harm, aggression, violence, damage to property, drug and alcohol abuse etc)
Do you/ person being referred have a restrictive practice authority in place?
Have you/or person referred ever experienced periods of detention for an offence? If so, please provide information about the nature of these offences including current orders, charges & bail conditions:
Relationship
Contact Details
Report Available?
Rationale - Please tell us why you believe you or the person being referred would be suited to the accommodation service, and reason for this application
History - Please tells us about your/ person being referred’s history of accommodation, including any previous accommodation breakdowns and reasons. Please give examples of what has worked and not worked regarding previous shared living/ accommodation services.
List of documentation attached to this application:
Print Name *
Name
Title
Relationship
