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Learning For Living – Referral Form
webtech@wejumphigher.co.uk
2021-01-05T10:22:09+00:00
Learning for Living Referral form
For use by external bodies to refer in to the Learning for living team.
Step
1
of
5
20%
Referrer name
Contact number (including area code)
Organisation
Hidden
Email address
Email address
Personal Details
Full name of applicant
Gender
Male
Female
prefer not to say
Date of Birth
National Insurance Number
Email Address
Address
(or known sleeping location of Rough Sleepers)
Post Code
Contact number
Benefits being claimed
Referral Requirement(s)
Hand Up Service (Rough Sleepers & Homeless)
Essentials Food, showers, clothes, access to Crisis support, Housing, benefits, homeless bank accounts, advocacy and Mental Health & substance Misuse – Appointments for non-urgent support needs, Physical Health & Medical Services
Yes we would like to make a referral to the HandUp service
No
Further Info
Mental Health Support
Specialist pathway, ongoing support to help manage mental health diagnosis, Crisis Café, Eco Therapy (Gardening)
Yes
No
Further Info
Employment Support
Job Club, Pre-employment courses, Accredited training programmes, work readiness support and our tailored Work Based Learning Placements (Hope Tools, Hope Catering, Foodclub & Warehouse, Allotment, Charity Shop, Painting & Decorating
Yes
No
Further Info
EUSS Application & Migrant Support
professional support to apply for settled status, tailored Migrant support inclusive of Employability service
Yes
No
Further Info
Independent Living Support
Cookery club, Budgeting & finances, Tenancy sustainment
Yes
No
Further Info
Substance Misuse Support
Access & Engagement to treatment, pre-contemplation, talking and therapeutic groups
Yes
No
Further Info
Social & Digital Inclusion
Hope Challenges, Creative Writing, Arts & Crafts, talking groups, Eco Therapy (Gardening), Tools upholstery & workshop, Women’s Group
Yes
No
Further Info
Additional Information
Do you have any concerns regarding the applicants suitability for this referral?
Yes
No
Further info
Are there any communication concerns or adjustments required to accommodate the client?
Yes
No
Further info
Are there concerns regarding access or additional assistance?
Yes
No
Further info
How long have you known the applicant? (years & months)
Consent to share – referring agency will be emailed a copy for your own records
I give full consent to for my personal details to be shared with Northampton Hope Centre to enable them to advocate with, and for me, to help resolve housing and other support needs Disclaimer: • I understand that this information may be used for statistical purposes. • I understand that this information will be held securely on paper and on computer in accordance with the General Data Protection Regulation 2018. • I understand that the information provided may be shared by Northampton Hope Centre with other organisations to support housing and other support needs. (This includes safeguarding escalation) Data will always be shared in line with legal obligations. • I understand that I reserve the right to view all data held by Northampton Hope Centre at any time in line with their data protection policy. • I understand that I reserve the right to ask for all data held on me by Northampton Hope Centre to be deleted at any time, though this may restrict the services available to me.
Name of person being referred
First
Last
Date
MM slash DD slash YYYY
Additional notes
Please use this space to add any further comments that are relevant to this referral submission
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