Make a Referral - Hope at Home

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.

If you would prefer to download a PDF copy of this form, please click here: PDF form.

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:

Country of origin: *

Ethnic origin: *

Languages spoken: *

Interpreter required?: *

Yes
No

NRM Status: *

If other, please detail:

Immigration status: *

If other, please detail:

Date of birth: *

Religion (if any):

Gender: *

Gender identity:

Cisgender
Transgender
Client did not wish to disclose

Do they have access to public funds?: *

Yes
No

Mobile number: *

Email

Current geographical location: *

Next of kin:

Details of any dependent children:

Do they have any dietary requirements?:

Type of exploitation experienced: *

Additional Information

Current accommodation and reason for the referral?: *

(eg CG decision agreed and exiting NRM, vulnerable to street homelessness)

Can they access services independently?: *

Yes
No

Are they a smoker?: *

If yes, approximately how many per day?

Do they drink alcohol?: *

If yes, how regularly?

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

Would they prefer to stay in current area or are they happy to relocate?: *

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

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.

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:

Support needed for literacy skills?:

Support needed for numeracy skills?:

Support needed for budgeting?:

What are their leisure interests?:

This helps our matching process

Do they have any debt?:

Please outline amounts if so

Please outline any current physical health issues or disabilities:

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:

Covid vaccination status: *

No vaccine
One dose of vaccine
Two doses of vaccine
Booster dose of vaccine

Eligible to work in the UK?: *

Yes
No

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: *

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: *

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

Any other safeguarding issues?: *

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

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 *

Please ensure that the client signs the consent and sharing information section as below. We cannot process the referral without this.

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 am happy for Hope at Home to contact other agencies, where it is necessary, for the purposes of my support.
• I agree that the information provided in this referral form is accurate.

Name: *