SWIFT
FLOATING SUPPORT INITIAL REFERRAL FORM DOMESTIC CLEANING ONLY Title
Mr/Mrs/Miss/Dr/Other
Full Name Address
Male Female Telephone Number Date of Birth
Type of Accommodation
Post code
If at current Address less than 5 years Please give Previous Address
Council Home Owner Hostel
Sheltered Housing Housing Assoc Adult Placement
Local Authority Care Private Landlord……………………………………….
NI Number
(Please give name)
Do you have help from other agencies?
Name of Next of Kin
Yes If yes, please give details
No
Phone Number of Next of Kin
Contact details of person completing form: Name Date
SP Use only HB/CTBn
Agency Designation Telephone
Notes (SP Use only)
Agency…………………………………… Date faxed ………………………….. FORM REVIEWED: 09/2007
What is most relevant to the type of support and housing that you need? E1 E2 E3 E4 E5 E6 E7 E8 E9 Domestic Abuse Learning Difficulties Mental Health Alcohol Issues Drug Use Physical Mobility Young and Vulnerable Criminal Justice Issues Single and Homeless
Domestic Cleaning
Is any additional help required?
(These will be forwarded to the SP team – some of these services are not yet available)
Form filling Shopping Befriending Advice and Counselling Budgeting Home Security Home Safety Life Skills Welfare Checks Gardening Other, please specify
E10 Chronic Illness E11 Single Parent
Please tell us the reason for this referral or if there are any known hazards If there is anything else you would like to tell us, please use this space.
DECLARATION
I confirm that I have given my permission to be referred for floating support SIGNED DATE
Please return this form to: Supporting People Team – Domestic, Hawtin House, Unit A, 1 Hawtin Park, Gellihaf, Pontllanfraith, Blackwood, NP12 2PZ, contact 01443 864548/01443 864551
THANK YOU FOR COMPLETING THIS FORM