REFERRER & ORGANISATION DETAILS
Referrer name:
Job title:
Organisation:
Date of referral:
Telephone:
Email:
Relationship to applicant:
Is the referring organisation currently supporting the applicant?
If yes, explain the support currently provided, frequency of contact, current concerns and any known risks:
POTENTIAL SERVICE USERS DETAILS
First Name:
Surname:
D.O.B:
NI No:
Current Address:
Contact Number:
FINANCIAL, BENEFITS, DEBTS AND ARREARS INFORMATION
Is the applicant eligible for Housing Benefit or housing costs support?
Please select
Yes
No
Unknown
Current benefits:
Please select
Universal Credit
ESA
PIP
JSA
Other
If "Other" please tell us what
Payment frequency, payment date and amount for each benefit:
Does the applicant have current or historic rent arrears, service charge arrears, debts, fines, loans, unpaid utilities, repayment plans or deductions from benefits?
Please select
Yes
No
Unknown
If yes, provide full details including amount owed, creditor/landlord, repayment arrangements, risk of enforcement and whether this may affect tenancy sustainment:
Does the applicant have current or historic rent arrears, service charge arrears, debts, fines, loans, unpaid utilities, repayment plans or deductions from benefits?
CONSENT, INFORMATION SHARING AND EXTERNAL AGENCIES
Has the applicant given informed consent for Community Interventions CIC Supported Housing to contact relevant professionals and agencies?
If no, explain the reason and identify the lawful basis for sharing, if applicable:
List all external agencies currently or recently involved, including named worker, role, organisation, telephone, email, involvement, frequency of contact and any risk information they hold:
COMPREHENSIVE REFERRAL RISK ASSESSMENT
Key Risk Areas to be Fully Explored
- Risk information must include: what the risk is, when it last occurred, frequency, severity, triggers, warning signs, protective factors, current controls, agencies involved, evidence source and what support or restrictions may be required.
Areas requiring detailed information: mental health, self-harm, suicidal ideation, physical health, medication, medication storage, PPPE/personal emergency evacuation needs, fire safety, convictions, probation/police involvement, violence or aggression, exploitation, safeguarding, substance misuse history, relapse risk, overdose risk, debts/arrears, visitors, tenancy conduct, anti-social behaviour, domestic abuse, risks to staff, risks to other residents and any risk that may affect placement suitability.
Sources of Information Used (Select Appropriate)
Please select
Self Referral
Social Services
Psychiatric Report
Hostel/Housing Provider Info
PSR
Victim
Previous Convictions
Family
Alcohol/Drug Agency
GP
Other Outreach Service
Other
CURRENT CIRCUMSTANCES
Does the applicant have any current or historic mental health diagnosis, symptoms, crisis episodes, emotional instability, trauma-related needs, psychosis, paranoia, anxiety, depression or other presentation that may affect their safety, tenancy sustainment or engagement with support? Include diagnosis if known, current symptoms, last crisis, triggers, medication, professionals involved, hospital admissions, risk plans and current concerns?
Please select
Yes
No
Unknown
Details:
Has the applicant ever received a diagnosis or professional assessment indicating personality disorder, anti-social behaviour patterns, impulsivity, emotional regulation difficulties or behaviour that may increase risk to self, others, staff, residents or the property? Include who made the assessment, when, current presentation, known triggers and recommended risk controls?
Please select
Yes
No
Unknown
Details:
Are there any obsessive, compulsive, fixed, repetitive or concerning behaviours that may affect daily living, relationships, safety, tenancy sustainment or engagement with support? Include examples, frequency, triggers, impact on others and any professional input?
Please select
Yes
No
Unknown
Details:
Does the applicant have any current or historic substance misuse, alcohol misuse, dependency, relapse risk, overdose history, injecting history, drug-related debt, drug-related associates, cuckooing risk or treatment history? Include substances used, frequency, last use, route of use, triggers, current treatment, scripts, detox/rehab history, abstinence periods, relapse warning signs and risks to self, others or the property?
Please select
Yes
No
Unknown
Details:
Is the applicant currently prescribed substitute medication or treatment linked to substance misuse, such as methadone, buprenorphine, subutex, suboxone or alcohol-related medication? Include medication name, dosage, prescriber, dispensing arrangements, collection frequency, remaining supply, engagement with drug/alcohol services, missed doses and any risks linked to storage, misuse, overuse or diversion?
Please select
Yes
No
Unknown
Details:
Is there any current or historic sexually harmful, sexually inappropriate, coercive, boundary-crossing or high-risk behaviour that may affect placement suitability, safeguarding or risk to others? Include what happened, who was affected, dates, police/probation involvement, restrictions, triggers and current risk controls?
Please select
Yes
No
Unknown
Details:
Is the applicant at risk of sexual exploitation, grooming, coercion, unsafe relationships, exploitation by associates or being pressured into activities that may place them or others at risk? Include known perpetrators or associates where safe to record, locations, frequency, protective factors, safeguarding referrals and current safety planning.
Please select
Yes
No
Unknown
Details:
Does the applicant show signs of self-neglect, poor personal care, hoarding, neglect of health needs, unsafe living conditions, poor nutrition, missed appointments or difficulty maintaining their accommodation safely? Include examples, severity, impact, current support and whether safeguarding concerns have been raised?
Please select
Yes
No
Unknown
Details:
Is the applicant socially isolated, disconnected from positive support networks or overly dependent on unsafe relationships or associates? Include positive contacts, risky contacts, family involvement, community links, loneliness concerns and how this may affect wellbeing, recovery or tenancy sustainment?
Please select
Yes
No
Unknown
Details:
Is there any current or historic risk of suicidal thoughts, suicide attempts, self-harm, overdose, ligature risk, risk-taking behaviour or statements of hopelessness? Include date of last incident, method, intent, planning, access to means, protective factors, crisis support, hospital involvement and current safety plan?
Please select
Yes
No
Unknown
Details:
Does the person have any medical problems that may be of a concern and needed specific care needs?
Please select
Yes
No
Unknown
Details:
Does the person have any allergies that may be of specific concern and could result in emergency medical treatment being required?
Please select
Yes
No
Unknown
Details:
Is the person less able to react to a fire alarm or fire? (mental health / cognitive or decision making difficulties / sensory impairments – hearing or sight loss)
Please select
Yes
No
Unknown
Details:
Does the person have a reduced ability to escape in the event of a fire? (physical/sensory/cognitive impairments)
Please select
Yes
No
Unknown
Details:
Are there any convictions of arson?
Please select
Yes
No
Unknown
Details:
RISK TO OTHERS
Is there any current or historic risk of violence, aggression, intimidation, hostility, threats, harassment, coercive behaviour or conflict towards staff, professionals, residents, family members, partners, neighbours or members of the public? Include who was affected, what happened, dates, frequency, severity, triggers, warning signs, police involvement and current risk controls?
Please select
Yes
No
Unknown
Details:
Does the applicant have any spent, unspent, pending or alleged offences, police intelligence, current investigations, court matters, restraining orders, licence conditions or restrictions that may affect placement suitability or risk management? Include offence type, date, sentence/outcome, current status, risk level, victim considerations and any relevant conditions?
Please select
Yes
No
Unknown
Details:
Has the applicant ever been convicted, investigated for, alleged to have committed, or been assessed as presenting a risk linked to serious violence, robbery, weapons/firearms, ABH/GBH, kidnapping, arson, sexual offences, offences against children, domestic abuse, exploitation, harassment or offences involving vulnerable adults? Include full details, patterns of behaviour, victims or targeted groups, dates, restrictions and professional risk assessments?
Please select
Yes
No
Unknown
Details:
Are probation, police, MAPPA, youth offending, courts, prison resettlement, victim liaison or any criminal justice services currently or recently involved? Include named officer, organisation, contact details, licence/order conditions, reporting requirements, risk level, restrictions, compliance concerns and whether they support the referral?
Please select
Yes
No
Unknown
Details:
Has the applicant ever made verbal, written, online, physical or implied threats towards any person, group, organisation or property? Include who was threatened, nature of the threat, dates, context, whether there was intent or planning, access to the person/place, police or safeguarding involvement and current controls?
Please select
Yes
No
Unknown
Details:
Is there a known victim, targeted person, targeted group or type of person who may be at risk from the applicant? Include relationship to the applicant, current contact or access, any safeguarding or victim restrictions, exclusion zones, non-contact conditions and actions required to reduce risk in supported housing.?
Please select
Yes
No
Unknown
Details:
Is the applicant known or suspected to carry, use, store, threaten to use, or have access to weapons or items that could be used as weapons? Include type of weapon, dates, circumstances, police involvement, whether weapons are still accessible and any restrictions or safety measures required.
Please select
Yes
No
Unknown
Details:
Are any other services involved because of risk to others, safeguarding concerns, offending behaviour, domestic abuse, exploitation, anti-social behaviour, mental health risk, substance misuse or tenancy-related concerns that have not already been recorded? Include agency name, named worker, role, telephone, email, reason for involvement and any risk information they hold?
Please select
Yes
No
Unknown
Details:
Which professionals, agencies or services has the applicant engaged with within the last 12 months, and are there any concerns about engagement, missed appointments, refusal of support or inconsistent contact? Include names, roles, organisations, contact details, frequency of engagement, current involvement and whether they can provide further risk information?
Please select
Yes
No
Unknown
Details:
Is the applicant likely to engage positively and safely with staff, house rules, key work sessions, risk management plans and professional boundaries? Include evidence of previous engagement, any history of disengagement, hostility, refusal of support, manipulation, dependency, missed appointments or behaviour that may impact staff safety or effective support?
Please select
Yes
No
Unknown
Details:
Is there anything else in the applicant’s behaviour, presentation, relationships, associates, communication, online activity, substance use, mental health, offending history, tenancy history or professional feedback that gives cause for concern about risk to others? Include details, evidence/source, current level of concern and actions required to manage or clarify the risk?
Please select
Yes
No
Unknown
Details:
Has the applicant ever assaulted, threatened, intimidated, harassed, verbally abused, stalked or behaved aggressively towards staff, professionals, emergency services, landlords, neighbours, residents or volunteers? Include what happened, dates, severity, injuries or impact, witnesses, police involvement, disciplinary action, current restrictions and measures required to keep staff and others safe?
Please select
Yes
No
Unknown
Details:
Are there any visitors, partners, family members, peers or associates who may increase risk to the applicant, staff, residents, neighbours, property or tenancy sustainment? Include names where appropriate, relationship, known risks, banned individuals, police/probation concerns, expected frequency of contact and visitor management actions required?
Please select
Yes
No
Unknown
Details:
What is the applicant’s accommodation and tenancy history? Include previous addresses, reasons for leaving, evictions, abandonments, warnings, anti-social behaviour, property damage, rent arrears, neighbour complaints, licence breaches and any learning or controls needed to sustain a new placement?
Please select
Yes
No
Unknown
Details:
Can the applicant manage the expectations of supported housing, including rent/service charges, house rules, appointments, room/property standards, visitors, boundaries, neighbour relationships and engagement with key work? Include strengths, known barriers, previous patterns and support required to sustain the placement?
Please select
Yes
No
Unknown
Details:
ADDITIONAL RISK AREAS REQUIRING FULL DETAILS
Does the applicant have any current or historic safeguarding concerns, either as an adult at risk or as someone who may present a risk to adults, children or vulnerable people? Include concerns raised, dates, agencies involved, safeguarding referrals, outcomes, current safety plans and any restrictions or support required?
Please select
Yes
No
Unknown
Details:
Is there any current or historic domestic abuse risk, either as victim, perpetrator or both? Include coercive control, stalking, harassment, non-molestation orders, restraining orders, police involvement, unsafe relationships, current contact, victim safety issues and whether supported housing may increase or reduce risk?
Please select
Yes
No
Unknown
Details:
Is the applicant at risk of exploitation, cuckooing, financial abuse, criminal exploitation, drug-related exploitation, pressure from associates or being used by others for accommodation, money, substances or criminal activity? Include known associates, locations, warning signs, previous incidents, safeguarding action and controls needed to protect the applicant and the property?
Please select
Yes
No
Unknown
Details:
RISK TO SELF
Has the person been known to self-harm?
Please select
Yes
No
Unknown
Details:
Does the person have a history of being exploited?
Please select
Yes
No
Unknown
Details:
Has the person been known to overdose?
Please select
Yes
No
Unknown
Details:
Has the person ever received hospital treatment for an overdose or self-harm?
Please select
Yes
No
Unknown
Details:
Does the person have history of non-compliance with anti-psychotic medication?
Please select
Yes
No
Unknown
Details:
Has the person attempted to take his or her own life before?
Please select
Yes
No
Unknown
Details:
CURRENT PRESENTATION
Does the person show insight about their previous behaviour?
Please select
Yes
No
Unknown
Details:
Does the person show remorse/understanding of previous behaviour?
Please select
Yes
No
Unknown
Details:
Is there a commitment and ability to maintain a change in behaviour?
Please select
Yes
No
Unknown
Details:
Is there a clear intent and/or plan?
Please select
Yes
No
Unknown
Details:
Is there a significant change in the person’s present circumstances, e.g.: abstinence from alcohol and drug use, progression of mental health, progression of relationship with self and others?
Please select
Yes
No
Unknown
Details:
SELF-ADMINISTRATION OF MEDICATION
What medication is the client currently taking? Include dosage and what they are taking them for. Is the client currently engaged with local drug services where they receive medication to maintain abstinence from street drugs? (for example, a script)
Has the medication been prescribed by their GP?
Is the resident responsible for administering their medication at present?
Is the resident mentally and physically able to self-medicate?
Can the resident open child resistant lids/blister strips; use their eye drops and inhalers, etc?
Can the resident read a label?
Please select
Yes
No
Unknown
Does the resident know: What the medicines are for?
Please select
Yes
No
Unknown
Does the resident know: How to take the medication?
Please select
Yes
No
Unknown
Does the resident know: What to do if their supply runs out?
Please select
Yes
No
Unknown
Does the resident know: What to do if there’s a problem with the medication?
Please select
Yes
No
Unknown
CONSENT
Has the individual been informed that this referral is being made and given consent for relevant information to be shared with the appropriate professionals/agencies?
If No, please state the reason::
INFORMATION SHARING DECLARATION
SUBMIT
