Make a Referral - Hope at Home - A Hosting Scheme for Survivors of Slavery

Please fill this in with as much detail as you can so that we are able to provide our hosts with an accurate picture of their potential guest. Welcoming a stranger into your home is not always easy, so the more information we can gather the more likely it is that the hosts will agree to the placement.

A copy of this electronic referral form will be emailed to you.

NB: We do not accept self referrals. Please find our referral criteria here

NB: Please ensure ALL information is completed in full and follow the notes throughout the form. If information is missing, this could lead to delays in placement or placement breakdown.

Your details

Please enter your details here.

Organisation making referral: *

Referrer: *

Key worker/support worker name

Email *

Phone number: *

Date of referral: *

Client details

Please complete details about your client here.

Client Name: *

Preferred Name:

Ethnic origin: *

Country of origin: *

NRM Status: *

If other, please detail:

Immigration status: *

If other, please detail:

Preferred language: *

Languages spoken: *

Interpreter required?: *

Yes
No

Date of birth: *

Do they have access to public funds?: *

Yes
No

Type of exploitation experienced: *

Other

Gender: *

Gender identity:

Cisgender
Transgender
Client did not wish to disclose

Preferred pronouns:

Religion (if any): *

Mobile number: *

Email *

Current geographical location: *

Do they have a local connection to this area?: *

Do they wish to remain in the current area?: *

Are they happy to consider relocation to another town / city?: *

Next of kin: *

Details of any dependent children: *

Do they have any dietary requirements?: *

Additional Information

Current accommodation and reason for the referral (eg CG decision agreed and exiting NRM, vulnerable to street homelessness)?: *

If positive RG, why is accommodation within the NRM no longer suitable? *

Please enter NA if this does not apply.

Has your client been assessed as a priority need for housing by a Local Authority?: *

Yes
No

If yes, please upload S184 form in the file upload box at the bottom of this form.

Can they access services independently?: *

Yes
No

Are they a smoker?: *

If yes, approximately how many per day?

Do they vape?: *

If yes, how often?

Do they drink alcohol?: *

If yes, how regularly?

Location of safe friends / family (if known): *

Cultural needs: *

(e.g. proximity to mosque or access to certain types of foods)

Approximately how many belongings will they bring with them?: *

How will these be transported to the host’s home?: *

*Please note it is the responsibility of the referrer to provide transport and their belongings.

Are they happy to live in a house with members of the opposite sex?: *

Are they happy to live in a home with pets?: *

Hope at Home provides temporary accommodation only. What plans are in place for accommodation options after Hope at Home (eg application to NASS, local authority housing etc)? *If an application to NASS, LA housing or other types of accommodation has been made, please provide the date of the application: *

Needs Assessment

Previous employment, training or voluntary work: *

What are their leisure interests?: *

This helps our matching process

Eligible to work in the UK?: *

Yes
No

What financial support are they receiving?: *

Other (please specify):

Are they currently?: *

Volunteering?
In education/training?
Taking part in local community / faith / sport / activity group?
Other (please specify)?

Other (please specify):

If none of the above options apply, would they like to in future?:

Do they have any debt?: *

Please outline amounts if so

Please outline any current physical health issues or disabilities: *

Do they have any current infectious diseases?: *

Please note, your client is not obliged to disclose if they have any infectious disease - if they decide they do not wish to, please select the second option "chose not to disclose". This is different from "none", which your client should select if they do not have any infectious disease.

Other infectious disease:

Please outline any diagnosed or suspected mental health issues: *

Please outline any past mental health issues: *

(please include history of suicide attempts or self harm)

Details of medication prescribed and taken: *

Ongoing support: *

Please outline details of ongoing support provided including name, contact details and organisation (we can only accept referrals where external professional support is in place).

Risk Assessment

In your opinion, are they suitable to live in a home with children under 16?: *

Details of any current substance or alcohol abuse: *

Details of any substance or alcohol abuse in the last 10 years: *

Is there any history of aggressive or challenging behaviour? If yes, please give details: *

Has there been any aggressive behaviour towards staff? If yes, please give details: *

Any known risk to hosts from gangs / traffickers looking for them?: *

Details of any ‘unsafe people’ they may have or contact: *

Any known geographical areas of danger: *

How do they get on with other tenants (if appropriate)?: *

Any other safeguarding issues?: *

Please outline any previous convictions or involvement with the police or the criminal justice system: *

Any other relevant information which would assist our matching process?: *

Supporting evidence

If an application to NASS, LA housing or other types of accommodation has been made, please provide evidence to show the date of the application.
Please upload any other relevant evidence to support this referral.

File Upload

Click or drag files to this area to upload. You can upload up to 3 files.

Declarations and consent

Referrer:
I have explained the Hope at Home hosting scheme to the person I am referring, and they understand this is a voluntary arrangement between both parties which may be terminated at any point. I have explained the referral process and they understand they will be provided with information of potential hosts, including house-rules, before making any final decision. I agree, to the best of my knowledge, the information within this referral form is correct.

Name *

First

Last

Date / Time: *

Date

Time

Signature *

Clear Signature

Please ensure that the client signs the consent and sharing information section as below. We cannot process the referral without this and we cannot accept verbal consent - this must be signed by the client.

Referred client: Data Consent Form

I authorise Hope at Home to hold on file details of my circumstances and other personal details, whether provided by myself or others, for the purposes of assisting with my housing situation and related issues.

For the purposes of the General Data Protection Regulations 2018, the data controller is Hope at Home.

Please confirm the following with the client.

• I am happy for Hope at Home to keep written and electronic information about me and to keep in touch with me in accordance with their data privacy notice.
• I understand that this information may be shared with hosts or external agencies in order to make the placement or safeguard anyone at risk.
• I agree to allow Hope at Home to share my information with other agencies, including those in the Modern Slavery Victim Care Contract, to help determine my eligibility for support.
• I agree that the information provided in this referral form is accurate.
• I give permission for Hope at Home to anonymise details of my hosting story and share them, in a completely anonymous format and without identifying me, on Hope at Home’s social media channels, website, other publications and in talks at public events.
Hope at Home promise to:
• Always be respectful in the images chosen
• Completely anonymise everything that is written.
• Accurately represent your story
• Understand your right to privacy
• I understand that I can withdraw this consent at any time.

Name: *

First

Last

Date / Time: *

Date

Time

Signature: *

Clear Signature

Your details

Client details

Additional Information

Needs Assessment

Risk Assessment

Supporting evidence

Declarations and consent

info@hopeathome.org.uk

Tel: 07923 246561

Placement/Referral Enquiries: 07842 416299 | 07566 778366

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