Self Referral Form for Housing Related Support
Name

First
Last
Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Email
Contact Number
Date of Birth *
National Ins No. *
In which district council area do you live?
 Babergh 
 Forest Heath 
 Ipswich 
 Mid Suffolk 
 St. Edmundsbury 
 Suffolk Coastal 
 Waveney 
Do you have problems with reading / writing
 Yes 
 No 
Please give details of requirments (e.g. language, Braille, Reading Difficulties)
Would you prefer the CARA team to contact by phone?
 Yes 
 No 
Are you homeless?
 Yes 
 No 
Are you at risk of being homeless?
 Yes 
 No 
Are you homeless?
 Yes 
 No 
Do you have to leave your home?
 Yes 
 No 
If so when?
Are you about to leave:
 Care 
 Hospital 
 Prison 
 Supported Housing 
 Temporary accommodation 
 Other 
If so when?
Are you about to move in to new accommodation?
 Yes 
 No 
Do you feel vulnerable - do you feel like you are not safe?
 Yes 
 No 
If yes please give details
Economic status *
 Full time employment (24 hrs or more per week) 
 Part time employment (less than 24 hours per week) 
 Govt. training / new deal 
 Job Seeker 
 Retired 
 Not seeking work 
 Full time student 
 Long / short term sick 
 Other 
Household Details
 Single 
 Couple 
Total number of people in the household
Is anyone in your household expecting a baby?
 Yes 
 No 
If you have any pets please provide details:
Housing *
 Council tenant 
 Housing Association Tenant 
 Private Tenant 
 Home Owner 
 With Friends / Family 
 No Fixed Abode 
 Temp. Accommodation 
Please provide Name and address of your landlord

Need for housing related support

Through housing related support we work to develop and sustain a service user's capacity to live independently in their home and whin the community. we aim to support a service user to do things for themselves and not do do it for them. Support workers will visit people in their own home. tyically this will be up to 3 hours per week. the service is short term and reviewed every 13 weeks. this service is FREE

Please tick all those that are relevent.
Avoid losing a home
 support to maintain accommodation and avoid eviction 
 support with setting up a home for the first time 
 support with managing day to day activities such as shopping on a budget, menu planning, maintaining the home 
Manage your Finances
 support to maximise income, including receipt of the correct benefits 
 support to reduce debt 
 support to obtain paid work 
Be Involved
 support to participate in training and/or education 
 support to engage in leisure /cultural /faith and/or informal learning activities 
 support to participate in any work-like activities, e.g. unpaid work /work 
 experience /work-like experience / voluntary work 
 support to establish contact with external services /groups /friends /family 
Be Healthy
 support to better manage physical health 
 support to better manage mental health 
 support to better manage substance misuse issues 
Be safe and secure
 support to comply with statutory orders and processes related to offending behaviour  
 support to better manage self harm 
 support to avoid causing harm to others 
Be Independent
 support to develop confidence and ability to have greater choice control and involvement 
Please explain why you feel you require support so we can manage your application. *

FOR MONITORING PURPOSES

We keep records of people who apply to us for support. This is to ensure that our service is provided on an equal basis without discrimination on the grounds of age, gender, race, ethnicity, sexuality, disability or religion. Any information you choose to give us will be treated in confidence and will be used for monitoring purposes only. It will not affect your application for support.

PLEASE TICK APPROPRIATE RESPONSE
Gender
 Male 
 Female 
Age
 Under 18 
 18 - 24 
 25 - 29 
 30 - 34 
 35 - 39 
 40 - 49 
 50 - 59 
 60 - 69 
 70 + 
Ethnicity
 White - British 
 White - Irish 
 Any other white background 
 Black or British Black - African 
 Black or British Black - Caribbean 
 Any other Black background 
 Asian or British Asian - Bangladeshi 
 Asian or British Asian - Indian 
 Asian or British Asian - Pakistaini 
 Any other Asian background 
 Mixed - White and Asian 
 Mixed - White and Black African 
 Mixed - White and Black Caribbean 
 Any other mixed background 
 Chinese 
 Traveller - Gypsy 
 Traveller - Romany 
 Traveller - Irish 
 Other 
 Prefer not to say 
Sexual Orientation
 Heterosexual 
 Bisexual 
 Gay 
 Lesbian 
 Prefer not to say 
Disablity
 Yes 
 No 
If yes Please specify below
 Mobility 
 Visual Impairment 
 Hearing Impairment 
 Mental Health Condition 
 Learning Disability / Difficulty 
 Progressive disability / chronic illness e.g. MS Cancer 
Other Disability - Please specify
Religion
 Christian (including Church of England, Catholic, Protestant and all other Christian denominations) 
 Buddhist 
 Hindu 
 None 
 Jewish 
 Muslim 
 Sikh 
 Not known 
 Other 
 Prefer not to say 

Declaration

I consent to the information provided on this form being passed to members of the SNAP Consortium (SNAP) and Flagship Housing Group (for those who live in Waveney) who will assess my eligibility, priority and need for a housing support service.

I understand that all information given will be treated as confidential and I give my permission to SNAP and Flagship Housing Group to seek or share any necessary information from or with other relevant agencies and organisations. This may include sensitive personal information, in compliance with the aims and objectives of the Central Access and Referral Agency and the Suffolk Holistic Floating Support Service.
Please tick to confirm that you have read and understand the above statment. *
 I consent 
Date Time *

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