London Housing Trust Eligibility Criteria , Assessment & Referral Form (Statutory Agencies)

The role of London Housing Trust

LHT provides supported accommodation to homeless clients with a defined support need. This form is the first test that we use in determining if the referred client is suitable for our service. We only take those clients who would benefit from LOW to MEDIUM Floating support. The main aim of our housing-related support is to develop and sustain an individual’s capacity to live independently in their home. Support may include learning domestic or life skills; assistance with applying for benefits, budgeting and managing debts; gaining access to other support or community services, finding out about work or training and resettlement support to help set up and manage a new tenancy.

Who can be referred for assessment?

LHT works with a range of single, vulnerable, people including the following

Young People at risk

Young People leaving care

Rough Sleepers

Vulnerable offenders

People with mental health difficulties

People with a mild learning disability

People who are dependent on drugs or alcohol

People with HIV & Aids

Refugees

People with complex or multiple needs

Victims of domestic violence

Please ensure that sufficient information is supplied regarding the clients circumstances

Please Include any supporting Documents

Once the referral has been made and the criteria are met you will be contacted to discuss the referral and arrange any further assessment required.

1. Referrers Details
Agency Name & Address (including postcode)
Referrer s Name
Date form completed
Position
Tel. No.	Fax No.
Email address
How long has your agency known the client?
2. Client Details
Surname
First Name (s)
Address
Date of Birth	Age
Gender	Female Male
Tel. No.
NI number
First Language/ Interpreter needed?
GP Details
Is client pregnant ? If yes expected due date
Is client on housing register? If yes, ref no
3. Next of Kin Details (optional)
Surname
First Name
Address
Relationship	Telephone No.

4. Clients Legal Status
Nationality
Has the client lived outside of the UK within the last 5 years? (dates & location)	No
Does the client have leave to remain? (please tick)	Indefinite Limited Expiry Date:
Are their any conditions attached to their leave to remain? (details)
Is client seeking asylum?
When did client arrive in the UK?
Has a decision regarding asylum claim been made? (details)
5. Current Accommodation Details
Private Rented Council Tenancy Supported Housing Foster Care Rehab Unit Hostel Friends/Family Approved Premises Housing Association Tenancy Name of HA Rough sleeping B & B Parental Home Hospital Ward NFA Foster Placement Residential Care Prison Other Please specify
6. Housing History (give details of accommodation over the last 5 years including hospital admissions, custodial sentences, periods in detox units and periods of street homelessness)
Address	From	To	Accommodation type	Reason for leaving/Landlord Contact
.
7. Institutional History
Address	Yes/No	Date of leaving
Care or hospital:
Prison/YOI:
Armed forces:
8. Discharge/Release Details (complete this section if client is currently on a hospital ward, prison, YOI or rehab unit)
Planned/expected discharge or release date
Discharge/release planning meeting date
9. Can you stay with friends or family whilst we complete our assessment? Yes No Client currently in private rented accommodation. However, he states he has been issued with a NTQ.
10. Clients Link To Lewisham, Bromley Croydon etc (specify the client’s current or previous connection to Lewisham. Evidence will be required)
Previously/Currently Parent/sibling Family Employment/Education resident in Lewisham association in Lewisham Rough sleeping/ Street activity
11. (i) Reason for loss of last settled home
Main Reason (select one)
Parents no longer willing or able to accommodate Other relatives or friends no longer willing or able to accommodate Non-violent breakdown of relationship with partner Violence: Violent breakdown of relationship, involving partner Violent breakdown of relationship involving associated persons Racially motivated violence Other forms of violence Harassment, threats or intimidation: Racially motivated harassment Other forms of harassment Mortgage arrears (repossession or other loss of home) Rent arrears on: Local authority or other public sector dwellings Registered social landlord or other housing association dwellings Private sector dwellings Loss of rented or tied accommodation due to: Termination of assured shorthold tenancy Reasons other than termination of assured shorthold tenancy Required to leave accommodation provided by Home Office as asylum support Left or leaving an institution or LA care: Left prison/on remand Left hospital Left other institution or LA care Other reason for loss of last settled home: Left HM-Forces Other reason (e.g. homeless in emergency, sleeping rough or in hostel, returned from abroad)

11. (ii) Secondary reason(s) for loss of last settled home (select all that apply)
Never had independent accommodation Had previous tied accommodation Sale of property History of rent arrears Relationship breakdown Escaping violence History of noise nuisance Inability to cope Escaping harassment Mobility difficulties affecting access Anti-social behaviour Current Rent arrears History of rough sleeping and street activity History of abandoning tenancies Overcrowding History of living in shared accommodation Evicted – noise nuisance Evicted – rent arrears Evicted – Other (Please state)

12. Additional comments section (use this section to highlight any housing management issues or any identified patterns in relation to the clients housing difficulties)
Support Required (Please state what support you are requesting and why) To be completed by referring agencies only NOT LHT staff
Type of support required and reasons: e.g. floating support rent deposit accommodation based
If you are requesting a placement in supported housing please explain why this is the most appropriate option?

14. Meaningful Occupation (please include current and past employment & training details and volunteering experience)
Employment/Training/Education details	From	To	Reason for leaving
15. Welfare Benefits & Income Details
Birth Certificate Information:	Birth certificate available
Income Type	Received since	Weekly Amount	Proof confirmed	Memo
Income Support
Jobseeker’s Allowance
Incapacity Benefit
State Pension
Severe Disablement Allowance
Disability Working Allowance
Housing Benefit
DLA (Mobility Component)
DLA (Care Component)
Occupational Pension
Statutory Sick Pay
Salary/Wages
Family Tax Credit
Care Leavers Allowance
Other (please state)
Total Weekly Income
Is applicant submitting sickness certificates	Yes No	If ‘yes’, since when?

Is the applicant likely to qualify for additional benefits/premiums?	Yes No
Does the applicant have any outstanding loans/debt? (If ‘yes’ complete below)	Yes No
Type of loan/debt/arrears	Amount outstanding	Weekly payments	Comment/Memo
Social Fund	Just under £1,000	Approx £10.00	Details to be confirmed
Benefit/Signing Office Detail
16. Welfare Benefit Support Need (tick all that apply)
History of discontinued benefits Loss of benefit book Not claiming full benefit entitlement No NI No. Difficulty signing up for benefits Change of address details needed Currently not receiving any income Not linked to GP for sickness certificates Currently payment through an appointee Not eligible for public funds Financial support via SSD
Support Needs
(ii) Primary Support Need (only tick one)
History of drug Mental health dependency/use Refugee Asylum seeker Learning Rough sleeping/street Mentally disordered difficulties HIV/AIDS activity offender Physical/sensory Young person at risk Young person Fleeing domestic disability (Under 18) (Care Leaver) violence Ex or current offender Alcohol dependency Traveller Single homeless Lone teenage parent with support (16-18 years) Sex Worker
(ii) Secondary Support Needs (tick all that apply)
History of drug Mental health dependency/use Refugee Asylum seeker Learning Rough sleeping/street Mental disordered difficulties HIV/AIDS activity offender Physical/sensory Young person at risk Care Leaver Fleeing domestic disability (Under 18) violence Ex offender Alcohol dependency Traveller Single homeless Lone teenage parent with support (16-18 years) Sex Worker
18. Ex-Offenders
Ex-offenders checklist (key characteristics and support – tick all that may apply. Mandatory if ex-offender.)
Type of Licence or Supervision Order Community Service Automatic Conditional Probation Order/ None Order Release Lic. Community Sentence Young Offenders Discretionary Cond. Extended Institution Licence Release Licence Life Licence Supervision Section 42 (2) Drug Rehabilitation Anti-Social Schedule 1 MHA Requirement Behaviour Order Offender High Risk/Dangerous MAPPA Offender Date Licence/Supervision Order Ends Level
Additional notes (include details of offences and/or conditions on licence and contact details of Offender Manager and Prison Officer)
19. Mental Health (specify the client’s mental health diagnosis)
MH Diagnosis
MH Checklist (Evidence is required of diagnosis)
Paranoid/delusional Poor anger management/ Suicidal ideation thoughts impulsive behaviour Suicide attempts Panic/anxiety CPA level: attacks Social phobia Paranoia standard CPA level : Enhanced Schizophrenia Depression On depot Receiving outpatient Personality Supported by Forensic Home Office treatment disorder MH Team Restriction
Contact details of Care Coordinator or other involved professional:
Additional Notes
20. Physical Health (specify the client’s physical health needs)
Physical Diagnosis
Physical Health Checklist (key characteristics and support – tick all that may apply)
Sensory impairment Stroke Motor-neurone disease Mobility difficulties Fatigue/tiredness Out-patient hospital treatment TB Other Please specify
Additional notes and details of current treatment
21. Substance Dependency Issues
Substance Misuse Checklist (key characteristics and support – tick all that may apply)
Alcohol On methadone maintenance/ dependent IV drug use reduction programme Drug dependent Completed rehab/ Attending counselling/ Known to detox programme day programme CARAT team DIP client Current or former client of; Novo LCDAS Equinox ARP Blenheim CDP Another treatment agency please specify Not engaging with drug treatment agency Is willing to engage with a drug treatment agency Level & pattern of alcohol or drug use. (amount taken and frequency) Drugs Client states that e is not currently engaged with any treatment agencies around his drug use as he has no current substance misuse issues. He advises that when he first moved into Miriam Lodge he was using Class As – he was smoking both cocaine and heroin. This was (as he states) due to the influence of others whom he met at Miriam Lodge. Client stated that he is cutting back on the amount of cannabis he uses and is trying to only smoke cigarettes. Alcohol He drinks Stella now and then but only when out with friends
Type of drug used
Heroin Crack Methadone Cocaine Solvents Cannabis Tranquillisers CAT/KAT Amphetamines Other prescribed (speed) Crystal Meth medication Ketamine Other Please specify
Additional notes including cost method of use (orally, intravenously etc…) and clients perception of their use
22. Other needs (use this section to update on client’s other needs)
Other needs
Additional notes:
23. Additional Support Assessment
Do you need support with the following?	Assessing Officer’s or Key worker’s view
Always	Sometimes	Not at all	Always	Sometimes	Not at all
Accessing other services
Accessing education/training
Debt/money management
Household chores (cooking, cleaning)
Applying for Welfare Benefits
Literacy support
Language & translation
Taking medication
Dealing with isolation
Are there any other areas you feel you need help with? Please state.
24. Supporting Documents Checklist (Tick all that applies. Please note that we are only able to process referrals where the supporting information is sent along with the referral form.)
Name/type of document (1-4 are the minimum documents to be provided)	Available on request	Attached
1. Proof of Identity & Nationality (passport, birth certificate)	On file
2. Proof of Income (wage slip, welfare benefits)	To follow
3. Proof of current address (tenancy agreement, current utility bills)	To follow
4. Risk Assessment Form	To follow
5. Psychiatric Report
6. Latest CPA Summary
7. Hospital Discharge Report
8. Housing Application Form
9. Community Care Assessment
10. OT or other health Assessment
11. Medical Self-Assessment Form
12. A Probation Summary
13. Summary of Previous Convictions
Other information (please specify)
25. Other services currently supporting the client or to which you intend to make a referral.
Service name & number	Contact person	Type of Support
Is the applicant aware of this referral to LHT? Yes No
Signature of referrer
Print Name
Date of application

Client Consent to disclose and obtain information

We need to obtain and share information about you with, and from, a number of agencies to enable us to assist you effectively.

1. In order to help you to access housing and support services, we need your consent to access information about you from other agencies such as housing benefit, your GP etc…

2. Information that you provide to the Single Homeless Intervention & Prevention service (LHT) will need to be shared with the services that we want to support you.

3. In order to ensure your safety and the safety of others we will always complete a risk assessment which will be shared with any services that we want to provide you with support.

4. Information will be shared on a need to know basis, where there is a specific and legitimate need to know.

I . (Print Name) have checked the information on this form and agree that it is accurate. I understand and consent to LHT contacting agencies in order to obtain information about me in order to make a full and accurate assessment of my situation. I understand and consent to the information given to LHT to be shared with other organisations and services. Signature: See HARD COPY……………….. Date: Witnessed by (staff signature and date) --------------------------------------------- ---------- Print name___________________________________________

To be completed by LHT staff
Recommendation	Comments
Prevention Initiative
Floating Support
Supported Accommodation
Part VII application
Assessment centre
B&B
Referral to another agency
Relocation
Advice /signposting only
No further action
More information needed