CENTRAL ACCESS POINT- (CAP) REFERRAL FORM

1 CAP REFERRAL 14112012 1 of 8 CENTRAL ACCESS POINT- (CAP) REFERRAL form The CAP is the REFERRAL and assessment route for people in need of Housing Related Support (HRS). The CENTRAL ACCESS Point (CAP) will: Complete an initial assessment, through a face to face meeting to identify the priority housing support needs when there is homelessness or serious risk of homelessness. (the District Local Authority will offer advice and assistance in the first instance) Where face to face meeting cannot take place a telephone assessment may be offered. Refer to the most appropriate service:- floating support or short term accommodation Sign post to existing services within local area where there is no identified housing support need Not be able to provide accommodation for homeless people.

2 Complete joint assessments with short term accommodation provider if appropriate Complete telephone assessment for people in prison 28 days prior to release (this will not guarantee short term accommodation) Service Eligibility You must be over 16 to ACCESS floating support and homeless or at serious risk of homeless to ACCESS short term accommodation, where appropriate Housing related support for people who are homeless or serious risk of homelessness includes: Support to establish and maintain existing accommodation support with accessing short term accommodation, where a person is homeless support with move on; setting up and maintaining a tenancy support with developing domestic and life skills, to help maintain and establish accommodation Support in accessing community services & developing independence.

3 (A list of eligible tasks is available on ). Consent to share must be given before a REFERRAL can be processed: I give permission for Cumbria County Council to share information contained within this REFERRAL and assessment and to contact any other relevant agencies involved in my care and support. I understand that the information on this form is true and correct and that any false or misleading information may lead to: My REFERRAL being cancelled If an offer of support has been made, then it may be withdrawn. I understand that the information on this form will be recorded on Cumbria County Council IAS data system. I understand the above: Signature of person being referred: _____ Date:_____ On completion the form may be returned: By Post : -Supporting People team; Adult & Local services; Cumbria County Council; 4th Floor Civic Centre, Rickergate, Carlisle CA3 8QG, FAXED to 01228 221476 FAO Supporting people CAP REFERRAL 14112012 2 of 8 PROFESSIONAL REFERRALS ONLY; Professionals referring to the CAP MUST provide the following information and fax the relevant documents with this REFERRAL .

4 If Available is and documents are not attached please state why. Document Request Available Name of document, Organisation & Date: Recent assessment completed by professional. Yes No Date: Recent Care Plan Yes No Date: Recent Risk Assessment & management plan Yes No Date: This form can be made available in large print, Braille, other languages or audio- if you require an alternative please ask. The information in SECTION A- 1& 2 and SECTION B-1&2 must be completed by the referring agent or a customer making a self referring. IF SELF REFERRING- and you are unable to fully complete this form , the local area coordinator will complete this with you at your initial meeting REFERRAL REQUEST INFORMATION (section A) SECTION A: - 1 background information Referrer details Date of REFERRAL : Name of person completing this from Contact Address of referrer (including postcode): Telephone Contact No E-mail address Organisation: Customer details: Name of person referred into CAP Contact address (of person being referred) Postcode Contact telephone number Gender of person being referred: Preferred method of contact to arrange initial assessment.

5 M F Mobile Letter via referrer Date of birth of person being referred (dd/mm/yyyy): Age: GP name & contact details: National Insurance number NHS number: Client group, please appropriate group /s Young person (18-25) Mental health issues Young person (16-17) Learning difficulties Care leaver Offender or risk of offending Teenage parent Substance misuse Single homeless Victim of Domestic violence Homeless family Prisoner due for release in 28 days CAP REFERRAL 14112012 3 of 8 Current Accommodation- settled Current Accommodation- unsettled Approved probation hostel Acute health care Mobile Accommodation Night shelter/hostel Owner occupier Prison/young offenders Living with Family or Friend Refuge Sheltered Accommodation Short term guest with friend-family Other settled (please specify below)

6 Rough Sleeper / squatting Other unsettled (Please specify below) If other please specify Has the person presented as homeless to Local Authority? Has Homelessness dept offered advice and assistance ? Has the person registered with choice based lettings (CBL) Has eviction notice been given Household composition: 2 adults & children: Single: Single with child: Multiple: Extended family: Couple: Other (please specify) Employment, Education & Training Details. Are you: Employed Unemployed Voluntary work Retired Are you enrolled in education /training Willing to enrol /positive engagement If applicable please record below: Job role or course title No of weekly hours Other information Have you accessed supported Housing services in the past?

7 Yes No If you have answered yes, please state where and when: Do you have any current rent arrears? Yes No If yes what is your outstanding balance? Do you have a repayment plan? Yes No Have you ever been subject to eviction proceedings? Yes No Where you answer a yes to eviction please give overview and dates Ethnicity Any other Asian background Any other Black background Any other ethnic group Any other mixed background Any other White background Asian British Bangladeshi Black African Black British Black Caribbean Chinese Gypsy/ Roma Indian Information not yet obtained Pakistani Traveller of Irish Heritage Refused White and Black African White and Asian White and Black Caribbean White British White European White Irish CAP REFERRAL 14112012 4 of 8 Please list the Reasons for REFERRAL : Please ensure you give an overview of what you expect in relation to housing related support.

8 A CAP REFERRAL / assessment will not be able to secure accommodation. Current Support: (Describe any help or support currently received list services eg drug services, health care; support groups, probation officer, social worker and also support from family / friends, carers and what you have done to address your housing situation) Other professionals involved in your support/ care: Name Organisation and address and brief overview of support given. Tel No (include code) Other significant People Relatives/Friends Name Relationship Contact Details (including address, phone number) CAP REFERRAL 14112012 5 of 8 SECTION A-2- Customer Identification of Need: This section must be completed by the referring agent or the individual.

9 The CENTRAL ACCESS Point will support people who are identified as vulnerable as outlined on page 1 of this REFERRAL from. Service provision to meet your needs based on further assessment. Please state why you believe this is the most appropriate service to meet your current needs Short-term accommodation- this provision is for customers that are: -currently homeless with housing support needs -at serious risk of homelessness with housing support needs. Accessing accommodation in this service will require commitment from you to: -develop independent living skills -engage with meeting your support needs Please note STA is not a means to accommodation where a person will not engage in support planning.

10 Floating support- the purpose of this service is to enable people to maintain their current accommodation or help find appropriate accommodation by: - engaging with support provider to address any housing support needs as identified at initial assessment -registering with CBL, submit timely bids -accessing private landlords -linking with family and friends -develop links with community -develop skills to maintain independence -engage with positive move on. Signposting- the CAP can provide you with up to date information and advice relating to a number of services currently available in your area to meet your needs where STA or FS is not appropriate. or can make appropriate REFERRAL to other agencies to meet your needs this may include REFERRAL to Local Area Coordinator Do you have any pets that you will need to be considered when applying for short term accommodation?