Risk of Rough Sleeping Service
Referral Form
Email Sender
Referral Date
/
Day
/
Month
Year
Referrer Details
First Name
Last Name
Role:
District Council
Phone Number
Please enter a valid phone number.
Email
example@example.com
Client Details
Client name
*
First Name
Last Name
Phone Number
Email address
example@example.com
Date of birth
*
/
Day
/
Month
Year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How would you describe your identity?
Female
Male
Trans
Prefer not to say
Pronoun
Self Describing
Non-binary
Prefer not to self-describe
Does your client consent to us contacting them by:
Text
Email
Phone
Letter
Nature of temporary accomodation (please provide details)
How can we support them? (description of drug and/or alochol use and reason for referral)
Physical health and related illness (example aclohol related dementia)
Diagnosis:
Mental Health
Autism
ADHD
Other
GP Summary
Type of Support Required
Substance misuse treatment
Floating Support
Any other assistance needed? (e.g. translation of access needs)
Any identified risks?
Other Relevent Information?
Debt
Rent arrears
Court Order/Possession Order obtained to evict from Home
Licence revoked – 7 days to move out of temp/shared accommodation
Submit
Should be Empty: