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Support referral form

If you are interested in our support service and would like to refer yourself or if you work with/are related to someone who could benefit from our support service, please complete the online referral form below.

Alternatively, if you would prefer to save the referral form and email the support referrals team later or print it and fill it in later by hand, you can view the support referral form from here.

If you/the person you are referring is receiving support from any other agency, e.g. psychiatrist, social worker, community psychiatric nurse, health service professional, etc, we will need contributions from all of these sources, detailing their involvement with you/the client, to be included in the referral.

If you have any queries about the form, please email support.referrals@viridianhousing.org.uk or call us on 0330 123 0220.

Thank you.

Client group

Service user groups *

Type of support *

Floating Support
Accommodation-based

Name of scheme referring to (if known)

Client details

Are you filling in the form on behalf of someone else?

Yes
No

If you are filling in the form on behalf of someone else, do they know about the referral?

Yes
No

If you are filling in the form on behalf of someone else, have they participated in the referral form?

Yes
No

Name *

Date of birth (dd/mm/yyyy) *

Address *

Line 1 *
Line 2
Town *
County
Postcode *
Country

Local authority/Council area

Telephone number *

Email address *

Risk areas

Please check the boxes next to the areas which you have/the person you are referring has displayed a risk and enter further details in the Risk information section below as appropriate.

Risk information

Please give further information about the Risk area(s) highlighted above where you have/the person being referred has displayed a risk.

Income & Benefits

If you are/the person you are referring is employed, what is your annual income?

Are you/Is the person you are referring receiving a pension?

Yes
No

If you are/the person you are referring is receiving a pension, please check the box next to the correct pension type.

State
Pension Credit

Are you/Is the person you are referring receiving housing benefit?

Yes
No

If you are/the person you are referring is receiving housing benefit, what is your housing benefit reference number?

Are you/Is the person you are referring receiving income support?

Yes
No

Are you/Is the person you are referring receiving disability allowance?

Yes
No

If you are/the person you are referring is receiving a disability allowance, please check the box next to the correct type.

Mobility
Care

Are you/Is the person you are referring receiving incapacity benefit?

Yes
No

Do you/Does the person you are referring receive employment and support allowance?

Yes
No

Are you/Is the person you are referring receiving jobseekers allowance?

Yes
No

Do you/Does the person you are referring receive tax credits?

Yes
No

Do you/Does the person you are referring receive attendance allowance?

Yes
No

Present Accommodation & Support: Please use section 1-10 to provide more information about your circumstances or those of the person you are referring and what support is required.

Section 1 - Accommodation

Please give details of the suitability of your current accommodation, or that of the person you are referring, as well as access to benefits, budgeting, ability to handle crisis, feel able to set up "home", feel safe and secure, level of confidence/isolation, living skills, engaged with move on activity.

Section 2: Living Skills

Please give details of your/the ability of the person you are referring to access benefits, self care, eating/shopping/cooking abilities, managing bills/rent and accessing services.

Section 3: Substance Use i.e. alcohol/drugs

Please give details of your or the person being referred levels of awareness/insight, willingness to change, extent of use, likely consequences of use, triggers, patterns, risks/vulnerability, engagement with services, criminal activity and enduring mental health issues.

Section 4: Mental Health

Please give details if you are or the person you are referring is at risk or in crisis, any presence of diagnosis, access to and engagement with services, use of medication, level of distress, insight and proactive/reactive in response to problems.

Section 5: Physical Health

Please give details of any ongoing physical health issues, access to GP, action required to improve health, engaged with treatment, use of medication, diet/lifestyle issues that may affect health and self-harm.

Section 7: Meaningful Use of Time

Please give details of your or the person being referred levels of motivation, social confidence, level of engagement, hopes/aspirations, existing relationships, problem areas and locations of family and friends.

Please give details of your or the person being referred in terms of the extent of isolation, ability to trust, social confidence, level of engagement, hopes/aspirations, existing relationships, problem areas and locations of family and friends.

Please give details of you or the person you are referring in terms of use of community resources, spiritual and lifestyle needs.

Section 10: Support

What do you think are the priority issues for you or the person you are referring and why do you feel that you or the person you are referring needs our support?

Other Support Providers

Please give the name and contact details of your next of kin or that of the person you are referring.

Please give the name and contact details of your GP or that the person you are referring.

Please give the name and contact details of your CPN or that of the person you are referring.

Please give the name(s) and contact details(s) of any other people who provide support to you/the person you are referring.

Details of Referrer - *please fill this in ONLY if you are completimg the form on behalf of the person being referred.

Referrers Name

Referrer's Job Title

Referrer's Address

Line 1
Line 2
Town
County
Postcode
Country

Referrer's Telephone Number

Referrer's Email Address

Signature (Referrer):

Date:-

Signature (You/ The person being referred): *

Date: *

Additional Information

If you are/the person you are referring is receiving support from any other agency, e.g. psychiatrist, social worker, community psychiatric nurse, health service professional, etc, we would ask for contributions from all of these sources, detailing their involvement with you/the person being referred, to be included in this referral. If you are unable to send any of the requested information electronically, please send them to us via the post: Freepost RSSL-TTHU-SYSR, Support, Viridian Housing, Colwell House, 376 Clapham Road, London, SW9 9AR.

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