Mental Health Floating Support Referral Form

Title: *

First name: *

Surname: *

Date of birth: *

National Insurance Number: *

Address line 1: *

Address line 2:

Town/City: *

Postcode: *

Ethnicity: *

Immigration status if applicable:

Phone: *

Email: *

Gender: *

Do you have your own tenancy / home? *

Do you have a mental health diagnosis? *

Emergency Name: *

Emergency Number: *

Emergency Relationship: *

Referrer name:

Referral service name:

Referral service address:

Referrer phone:

Referrer email:

Has the customer agreed to this referral?

Please provide your landlord’s details: *

Please provide details of any current housing issues eg rent arrears, notice to quit/eviction , ASB, repairs, other: *

What do you require support with, please select and provide details where necessary? *

Any other Support needs?

Do you consider yourself to have a disability or any other health issues? *

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

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: