Mental Health Floating Support Referral Form

Title: *

Please Select

First name: *

Surname: *

Date of birth: *

Day

Month

Year

National Insurance Number: *

Address line 1: *

Address line 2:

Town/City: *

Postcode: *

Phone: *

Email: *

Gender: *

Ethnicity: *

Please Select

Immigration status if applicable:

Emergency Name: *

Emergency Number: *

Emergency Relationship: *

Are you a referral service? *

Yes

No

A mental health diagnosis is required to be accepted to this service. Please state what diagnosis you have: *

Do you have your own tenancy / home? *

Yes

No

Tenancy type: *

Please Select

Please give details below: *

Housing *

Yes

No

Finances *

Yes

No

Mental Health *

Yes

No

Physical Health including mobility difficulties *

Yes

No

Activities, Education, Training, Paid work, Voluntary Work *

Yes

No

Any other support needs? *

Yes

No

Are there any issues around drugs/alcohol that you feel we may need to be aware of? *

Yes

No

Please give details below: *

Are there any other issues that may restrict your engagement with our service or concerns that the BCHA Mental Health Floating Support Team should be aware of? Please make reference to any offending behaviour:

Please ensure this form is fully completed and signed, as we may be unable to proceed without the information. Once received, we will contact you to arrange assessment. *

By signing this document, I agree with BCHA’s Privacy Notice and give consent for BCHA to share any of the above information with third parties if a risk is disclosed. *

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Mental Health Floating Support Referral Form

Client Details

Emergency Contact

Referral Service Details

Mental Health

Housing

Support Required

Important Customer Information

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