Haringey Logo

| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Password must contain the following:
  • 12 Characters
  • 1 Uppercase letter
  • 1 Lowercase letter
  • 1 Number
  • 1 Special character

Assessments and Referrals Form

Referrer Details







Client Details








If answer is ‘self-described’ please state




Client Links to Borough of Referral


GP Details


Next of Kin Details



Children (if applicable)



Pets (if applicable)

Recent Housing History


























Housing Management & Reason for Referral

Please highlight why the client is homeless, issues with housing in the past, specific housing related needs, as well as their ability to manage a tenancy. If the client has previously been evicted from supported housing, please include details of this.
Housing Management & Exclusion Areas
Please highlight if there are any areas or hostels within the referral borough where there are safety concerns, e.g. gang related, domestic abuse and perpetrator locations, etc.
Employment & Skills


























Benefits & Income





















Savings, Outstanding Loans, Debt or Rent Arrears

Does the client have any savings, outstanding loans, debt or rent arrears? If, yes, please complete the below section.

E.g rent, loan, arrears etc.




E.g rent, loan, arrears etc.




E.g rent, loan, arrears etc.




Welfare Benefit Support


Assets & Strengths

Please include clients likes, achievements/ what they are proud of etc.

E.g. what does a good day look like, positive relationships with their community, peers, family and services.
Support Needs



Please provide an explanation of the Support Needs indicated above, triggers and how the client likes to be supported in these areas.
Care Details







Mental Health Detail



Brief explanation of any therapy / mental health interventions the Client is currently attending.

If the specific date is not known then please enter an estimated date.





Mental Health Diagnosis Details



Other details / What support does the Client need / additional notes (e.g. upcoming Assessments, hospital admissions, etc.)
Physical Diagnosis Details

Please enter N/A if not applicable.




Brief explanation of any therapy / interventions the Client is currently attending to address physical health needs.




Substance Dependency Issues









Brief explanation of any therapy / interventions the Client is currently attending to address needs.




Elderly / Frail Checklist


Ex-Offenders Checklist





If the Client is on probation, please include current risk of harm information.

Details of Client engagement with services in custody (e.g. mental health, drug & alcohol services, anger management treatment, ETE Courses).

Planned Referrals by prison services / probation offices to external agencies.





Additional Support Assessment


Risk Assessment

Risk of violence towards others and property.
















If the Client has children / joint care of their partner's children, have Social Services been involved with the children?




Vulnerability from Others / Safeguarding Issues













If the Client was a victim of domestic abuse, are they still in contact with the perpetrator?


If the Client has been referred to MARAC please state the Lead Worker's name and contact details.

Risk of Self-Neglect / Vulnerability to Abuse

Including eating disorders.



Or other inability to express needs?


Poor awareness of personal safety / safety of valuables.


Poor ability to look after cleanliness and safety of home.



Evidence of failure to seek medication attention for ill health / addiction or concerns about ability to look after health needs.

Previously subjected to violence, harassment, abuse or death threats from close family / 'gang' members or others and/or weapons have been used against them.


Presenting Risks Action Plan


i.e. experience best practice with Client.
File Upload

Appendix 1: Under 25 Year Old Applicants

History of missing from home/placement and or school.

Involved in gang activity/known to gang members.



Evidence or suspicions of grooming activity.

STI, pregnancy, miscarriage or termination.

Evidence of expensive possessions unaccounted for.


Sexual relationship with significantly older person (more than 5 years).

Physical injuries and or disclosure of sexual assault then retracting statement.

Concerns around internet use – sharing inappropriate images/online relationships/offline relationship.

Receiving unaccounted for money or goods which appear to be about recruiting others to CSU.



Under 25 Safety Questions


Are there any areas in (borough of referral) where you might feel unsafe?

Do you feel at risk from anyone? If yes, from whom and why? You should gather as much detail as possible.

Is there anyone that you know lives in supported accommodation that you would feel unsafe to live with? If yes, from whom and why? You should gather as much detail as possible.

Do you feel at risk from any particular group/gang.

Would you say that you are involved in a gang? If yes which one? Emphasise that this is so they are not placed in supported accommodation with opposing gang members or their associates.

Do you think that other people may think you are in a gang? If yes, which one? Emphasise that although they may not be in a gang, if other people think they are, the risks can still be high.

Are any of your friends in a gang? If yes, which friends? Emphasise that who their friends are may influence where they can be housed safely.
Young Parents



DOB of child needing accommodation with parent.




Will the child be raised by a single parent.
Save my progress and resume later | Resume a previously saved form

Contact Information