EASTERN HUB - Homeless Assessment Form Last Updated – 4th August 2014

Referral to:

Date Completed:

Care First Number: (if applicable) HRIA Score:(Essential)

Agency Completing Referral

Completed By

Contact Details(email/Ext)

Client ForenameAKA

Surname

Date of Birth Gender NIN

Are you Pregnant:

Yes/No/NA If yes, when is your Due Date?

Contact Details:

Email Address

Next of Kin Name NOK Contact Numbers: Relationship

Single ☐ Couple ☐ Family ☐Other Household Members

NB - Only complete this section if you have other members of your family, who will be

accommodated with you

Yes☐

No☐

N/A☐

Partners Details:Forename

AKASurname D.O.B

Date of Birth Gender Relationship

Nat Ins No Contact number

Children’s Details:Forename

AKASurname D.O.B

ForenameAKA

Surname D.O.B

ForenameAKA

Surname D.O.B

ForenameAKA

Surname D.O.B

Do you have a local connection?

Yes Exeter ☐ East Devon ☐ Mid Devon ☐

Details:

If No - Where?

Are you Ex Services?Service Number:Squadron Info:

Have you been in LA care?If Yes, when and where?

Do you have a pet/pet’s?If Yes details:

Is it/they registered, chipped, vaccinated?If not please refer to the Dogs Trust *

Yes* No

*A copy of the relevantDocumentation is required. Please attach.

Do you have ID? Birth certificate, Adoption papers, Marriage certificate, passport, driving licence, utility bill etcIf No, would you like support to get some?

1

What is your Current Situation? How Long?

Details:

Housing Options Discussed

Details:

Are you are a Rough Sleeper (if yes, please complete next section)If No, go to Housing/Rough Sleeping History

Yes No N/A

What date and time do you arrive here? How and why did you come here?

Where previously have you engaged with services?

Q’s 1 to 5 only applicable for rough sleepers

1 Are you new to rough sleeping?Yes No

2 If No: - Is this the first time that you have slept rough in this area?Yes No

3 Have you returned to rough sleeping in this area after sustaining accommodation for longer than 6 months? Yes No

4 Are you equipped for rough sleeping?Yes No

5 Where are you rough sleeping?

Housing/Rough Sleeping History

Last Settled Accommodation

Hostel☐

B&B☐

Squat☐

Private Rented☐

Family/Friends☐

Detox/Rehab☐

Prison☐

Supported Housing

☐

Council / Housing Association

☐

Hospital☐

Other (Details)☐

Accommodation History(last 5 years if possible)

Date from Date to Type & location of Accommodation Reason for Leaving i.e evicted (why), family breakdown, discharge etc

D.H.C Are you registered on Devon Home Choice: Yes No If YES what band?

2

Income and Benefits

Are you in receipt of any benefits or

income?

(weekly, fortnightly, monthly)

Income

£……….

W/F/M

ESA

£……….

W/F/M

JSA

£………..

W/F/M

INS

£…………

W/F/M

DLA

£………..

W/F/M

Big Issue

£………

W/F/M

Other

£……….

W/F/M

Partners Details

Income

£……….

W/F/M

ESA

£……….

W/F/M

JSA

£………..

W/F/M

INS

£…………

W/F/M

DLA

£………..

W/F/M

Big Issue

£………

W/F/M

Other

£……….

W/F/M

Details of Employment

You

Work / Voluntary Work/Employer Details

Average Hours per week:

……………………………….Weekly / Monthly Pay: …………………………………..

Employer…………………………………

Partner

Work / Voluntary Work/Employer Details

Average Hours per week:

……………………………….Weekly / Monthly Pay: …………………………………..

Employer…………………………………

Location of Benefits office

Date of last payment Paid into Bank Account or GIRO?

Priority Debt Priority Debt outstanding to: Amount £

Non Priority Debt Outstanding to:

Amount £

Do you have any difficulties with money, budgeting, gambling?

Physical Health Information (you and any household members)

Registered with a GP? YES NO

If yes, where and contact number and/or address

Any current Physical Health Problems YES NO

Brief Details:

Taking any Prescribed Medication? YES NOIf yes, please list all medications, and dose/frequency:

Need reminding to take medications?YES NO

Who may be a risk if medication is not taken?Please specify and why?:Blood Born Virus information: e.g. Hep B/C, HIV? YES NO

Details

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Mental Health Information (you and any household members)

Experienced Mental Health Difficulties? YES NO

If yes brief details

Has this been diagnosed? YES NO

Involved with Mental Health Services/CPN? YES NO

Details:

Currently receiving any medication and/or treatment for Mental Health difficulties? YES NO

Details:

Ever been under a Mental Health section? YES NO

If yes, please provide details, where and when?

Substance Misuse Information (you and any household members)

Use Drugs and/or Alcohol? YES NO

Use Legal Highs? YES NO

If yes, please give details such as type, quantity, regularity, combinations etc

Any problematic behaviour whilst under the influence?Working with any drug/alcohol support services? YES NO

If yes, details, if no, do you want to be?

Legal Information (you and any household members)

Any warrants Outstanding?YES NO

Details:

On Bail, Supervision Order or due to appear in court?YES NO

Details:

Registered with Probation?YES NO

Details:

YES NO4

Registered with MARAC or MAPPA? (you and any household members)

Details:

Criminal Justice InformationMost recent conviction and full detail of Previous Convictions/Cautions

Details incl. datesYES NO

Been convicted of a serious violent offence?

Details incl. datesYES NO

Been convicted of an Arson Offence?

Details incl. datesYES NO

Been convicted of a sexual offence?

Details incl. DatesYES NO

Number of custodial sentences

Details incl. datesYES NO

Prison Details (if applicable)

Prison Number:

Release Date:

Which Prison: HMP

YES NO

Interagency Consent to Share5

It has been explained to me that information about me such as health, welfare and housing needs, may need to be shared between different agencies in order to help me access appropriate services. I understand that any information divulged will not be shared outside the authorised organisations, unless there is an identified risk to yourself, others or property.

DWP / Benefits Agency / Employment YES NO

Your GP / Health Services YES NO

Social Services YES NO

Health Visitor YES NO

Midwife YES NO

Mental Health Services YES NO

RISE (Recovery and Integrated Services) YES NO

Your Local Authority Housing Advice Team**please state where you are currently registered

YES NO

Sanctuary Supported Living YES NO

Shilhay / Esther Community / BCHA (Acc. Providers) YES NO

Accommodation Providers YES NO

Probation Services / PORCH YES NO

St Petrock’s YES NO

Police YES NO

Other:Details:

YES NO

NB - Where we are informed of additional agencies at a later date, a new consent form

must be completed and signed

Name: Signature: Date:

NB – Only to be used in isolation from main HUB Referral, for Severe Winter Provision Placements 6

GENERAL INFORMATIONClient Full Name: D.O.B.

Partner Name: D.O.B.

Are any children on the Child Protection Register

(if client is pregnant – state due date)Is the client aware of this Risk Assessment

YES NO If NO, please explain why:

EVIDENCE OF:- WHERE KNOWN DATE(S) AND DETAILS OF LAST OFFENCE (If Known)

Schedule One Offence YES NO

Serious Violent Offences YES NO

Arson YES NO

Damage to Property YES NO

History of Vandalism YES NO

SECTION 1Risk of Harm to Others (Violence & Abuse): Yes No Don’t know FURTHER COMMENTS

(inc. known triggers)1. Current behaviour/demeanour is threatening or abusive Yes No Don't Know2. Previous incidents of violence or physical aggression Yes No Don't Know3. Expressing intent to harm others Yes No Don't Know4. Evidence of intent to harm others (e.g. keeps weapons or knives etc)

Yes No Don't Know

5. Poor engagement with services and/or concernexpressed by others.

Yes No Don't Know

6. Poor engagement with care plan Yes No Don't Know7. History of drug/alcohol misuse Yes No Don't Know8. Custodial sentences or arrest for violent behaviour Yes No Don't Know9. Previous history of abusing others (see also section A2). Yes No Don't Know10. Close associates/pets known to be aggressive Yes No Don't Know

RISKMust be

completed

Significant & Volatile(High)

Significant but Stable (Medium)

Low/Minimal(Low)

SECTION 2Risk of Harm to Others (Sexual Offences Yes No Don’t Know

FURTHER COMMENTS(inc. known triggers)

Previous History of Offending or Sexually Inappropriate Behaviour Yes No Don’t KnowIf yes, please specify:

RISKMust be completed

Significant & Volatile(High)

Significant but Stable (Medium)

Low/Minimal(Low)

SECTION 3Risk of Self-Harm/Suicide:

Yes No Don't Know FURTHER COMMENTS(inc. known triggers)

1. Current suicidal thoughts Yes No Don't Know2. Current self-harming behaviour Yes No Don't Know

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RISK ASSESSMENT(THIS RISK ASSESSMENT MUST BE SIGNED BY CLIENT)

3. Feelings of Hopelessness/Helplessness/Loss of Control/Isolation

Yes No Don't Know

4. Recent significant life events Yes No Don't Know5. Poor engagement with statutory services/concernexpressed by others

Yes No Don't Know

6. Previous self-harming behaviour Yes No Don't Know7. Previous suicide attempts Yes No Don't Know

RISKMust be completed

Significant & Volatile (High)

Significant but Stable (Medium)

Low/Minimal(Low)

SECTION 4Risk of Self-Neglect/Vulnerability to Abuse

Yes No Don't Know FURTHER COMMENTS(inc. known triggers)

1. Failure to eat/drink properly Yes No Don't Know2. Socially/Culturally Isolated Yes No Don't Know3. Poor Personal Hygiene Yes No Don't Know4. Inappropriate clothing Yes No Don't Know5. Lack of daily occupation Yes No Don't Know6. Evidence of failure to seek medical attention for ill health/addiction or concerns about ability to look after health needs

Yes No Don't Know

7. Financial difficulties in meeting basic needs Yes No Don't Know8. Learning Difficulties/Disabilities or other inability to express needs

Yes No Don't Know

9. Poor awareness of personal safety/safety of valuables Yes No Don't Know10. Poor ability to look after cleanliness and safety of home Yes No Don't Know12. Poor engagement with services and/or concern expressed by others

Yes No Don't Know

13. Previously subjected to violence, harassment, abuse or death threats from close family/others or weapons havebeen used against them

Yes No Don't Know

14. Subject of current/recent MARAC (domestic violence) Yes No Don't KnowRISK

Must be completedSignificant & Volatile

(High)Significant but Stable

(Medium)Low/Minimal

(Low)

SECTION 5Does the client have any Special Dietary Requirements?

YES NO DON’T KNOW

If Yes, please specify

SECTION 6Does the client have any other Special Needs?

YES NO DON’T KNOW

If Yes, please specify

SECTION 7Does the client have a history of non payment of Rent?

YES NO DON’T KNOW

If Yes, please specify

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SECTION 8Does the Client wish to Add Any Other Information?

YES NO DON’T KNOW

If Yes, please specify

Client’s & workers perceptions of any risks identifiedSection Summary of Client’s Perception of Risk

This assessment has been sent by

EMAIL BY HAND

POST FAX SENT ON

/ /

Please also complete the HRIA (page 12) and Client/Worker Action Plan (Appendix 1)

THIS ASSESSMENT MUST BE REVISED IF AN INCIDENT OCCURS WHICH CHANGES THE LEVEL OF RISK

EQUAL OPPORTUNITIES

To help monitor equality and access to housing, would you please provide the following information:

1. Are you:Male: Female: Transgender:

2. Do you consider yourself to have a disability? Yes / NoIf yes, what is the nature of your disability?Physical Impairment Wheelchair User

Mobility Impairment Other

Sensory Impairment Sight 9

DECLARATION

Signature of Person Completing Form

Name Signature Date

Signature of Client (if applicable)

Name Signature Date

if the Client refuses to sign or is not present to sign this assessment and give brief reason below:

Hearing Other

Mental Impairment Learning disability Other

Are you registered disabled? Yes / No

3. How would you describe yourself? (please tick one box)White: British

Irish Any other White background

Asian or Asian British: Bangladeshi Indian Pakistani Any other Asian background

Black or Black British: African Caribbean Any other Black background

Chinese: Mixed: White and Asian

White and Black African White and Black Caribbean Any other mixed background

Any other Ethnic Group: Please specify ……………………………………..

4. Please indicate the main religion of your household:Baha’i Hinduism Scientology Buddhism Islam Shinto Christian Jainism Sikhism Confucianism Judaism Zoroastrian/Parsi Daoism Rastafarianism Other/No Religion

5. How would you describe your sexual orientationOpposite sex Same sex Both sexes

6. DeclarationI agree this information may be kept and used to help you to monitor and develop services that ensure full equality of opportunity. ORI would prefer not to give this information

Signed ……………………………………………… Dated………………........…

This assessment has been developed in partnership with the following organisations

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Please return your completed forms (if applicable) by post or email;

Clients with Complex Needs and 25 and For Clients 18-24 Years Old over. Referrals to go to:- Referrals to go to:-SHOT (Street Homeless Outreach Team) Young Persons Accommodation ForumC/O Gabriel House C/O Young Devon10 Smythen Street Exeter YES CentreExeter George StreetDevon ExeterEX1 1BN EX1 1DA

Email: ExeterSHOT@bcha.org.uk Email: exeter@youngdevon.org

Telephone: 01392 278551 Telephone: 01392 331666

Floating Support Referrals to go to:-Kaye Smart Local Service ManagerSanctuary Supported LivingEstuary HousePeninsula ParkRydon LaneExeter, EX2 7XE

Email: Kaye.Smart@sanctuary-housing.co.uk Telephone: 07436 805846

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Homelessness Risk Impact Assessment Version April 2013Name:

Category 0 1 2 3 4 5 Score

Homelessness No Issue Sofa surfing Notice to quit/possession notice issued.

Asked to leave by parents/friends.

Sofa surfing and rough sleeping. Move on from supported accommodation. Landlord has initiated bailiff action. In temporary accommodation.

Discharge from hospital or release from prison Rough Sleeping

Family Support(only to be completed if there are other household members to be accommodated)

No Issue

Could benefit from signposting to access local services / schools

Expectant new parent would benefit from signposting to local support servicesLives in unsafe or deteriorating housing or housing overcrowded for family size

No previous experience of living independentlyPoor rental history and references

Open case to Social Services after recent MASH referral Inadequate resources to obtain food for family

Open case to Children’s services. Children are subject to Child Protection Plan.Recent referral to Targeted Families

Floating Support(Only to be completed if you are applying to support client in a general needs property)

No Issue

Could benefit from signposting to access local services

Lives in temporary or transitional housing and has not secured permanent housingCannot meet basic needs

Moving on from Supported accommodation, transitional support needed to assist set up of utilitiesPoor rental history and references needs support to prevent future homelessnessRent and bills in arrears

Court action pending or has already been takenNew tenant with no previous experience of living independentlyNeeds support to access vital healthcare services

Notice served on property. Floating support needed to ensure that homelessness is preventedEmergency placement with no previous experience of homelessness, no benefits in place

Income and financial status

No Issue

Working/claiming all entitlements with non-priority debt issues requiring agency intervention.

Not claiming all entitlements. May have non-priority debt requiring agency intervention.

No income, no claims in situ. Needs urgent help to maximise income. Priority debt(s), requiring agency intervention

Priority debt(s) needing urgent agency intervention, which includes rent arrears – putting tenancy at risk

Mental and emotional health (MH) No

issue

Current or recent MH difficulty and/or prescribed meds but currently stable&managed by GP or other service. Stress of situation affecting ADL.

Current or recent MH not currently stable but engaged with GP or MH service. Low risk of harm to self/others. Stress of situation significantly affecting ADL++

Current MH difficulty, not currently engaged or patchy engagement with GP or other MH service. MH deteriorating, MH intervention would be helpful. Low/med risk of harm to self/others.

Current or recent MH (within last 12mths) behaviour suggests med/high risk to others. Recent inpatient hosp. admission or discharge. Engaged with services& care co-ordinator

Current MH difficulty. Behaviour suggests a med/high risk of harm to self/others. Not engaging with health services, with or without a care co-ordinator. Regular user of A&E, crisis health services.

Physical Health (PH) No Issue

Recent or current PH issues maybe prescribed meds, currently stable and managed by GP or other services

Chronic PH issues, managed by GP and or secondary care Acute or chronic PH not stable requiring

intervention from GP/Outpatient/Hospital

Regular user of A&E, Crisis or Inpatient Services for acute /chronic PH problemsLow self-care/poor diet

Requires treatment or hospitalisation for physical health problem. Failure to seek attention or not engaging with services or early self-discharge

Learning, understanding or Communication difficulties

No Issue

Require some support in understanding forms/agency roles&available assistance. Some advocacy required.

May require support in keeping/attending appointments or help in articulating needs to other agencies.

Difficulty reading/writing or comprehending documents/forms. Dyslexia or supported by Special Ed facility in past – may only seek help with paperwork when in a crisis

May lack insight into learning or communication difficulties.No formal diagnosis made or sought.Reluctance or inability to engage with supportive interventions

Diagnosed LD e.g. (Autism, Asperger’s, ADHD or other). Communication or behaviour requires additional support or presents a risk to others

Substance Misuse or other addiction

No Issue

History of drug, alcohol (substance misuse) or other addiction =< last two years

History of addiction/misuse =< 12mths or move on from supported/rehab accomm. Currently stable & engaged with services

History of or current addiction/ misuse =< 12mths or move on from supported/rehab accomm. Not engaged with services, w/wo problematic behaviour

Current/recent misuse in past 6 months, requiring intervention, occasional lapses and/or problematic behaviour but engaged with services.

Current/recent misuse, not currently engaged with services, chronic dependency/history of non-engagement with services and/or Dual diagnosis

Offending and/or Anti-Social Behaviour

No Issue

Historical police cautions, criminal convictions etc as an adult or significant juvenile offences

Historical police cautions or convictions within last 5 years for less serious offences, drunk and disorderly/incapable, section 5 public disorder act.

Difficulties in securing accommodation or loss of accommodation due to anti-social behaviour, criminal convictions, prison sentences or historical violent related incidents within last 5 years

Current or recent (within last five years) Probation/Supervision order ABC/ASBO Problematic street behaviour,known violent behaviour/convictions

Recent prison sentence (within last year)/conditions on release - Tag/curfew/order. Schedule 1, prolific offender, any arson or drug supply conviction (within last ten years

Engagement with frontline services

No issue

Usually keeps appointments and routine activities; usually complies with reasonable requests; involved in tenancy/treatment

Usually keeps appointments and routine activities; usually complies with reasonable requests; involved in tenancy/treatmentbut needs support, reminding and encouraging

Follows through some of the time with daily routines or other activities; usually complies with reasonable requests; is minimally involved in tenancy/treatment

Non-compliant with routine activities or reasonable requests: does not follow daily routine, though may keep some appointments.

Does not engage at all or keep appointments

Risk to self/others or form others

No issue

Minor concerns about risk of self-harm/suicide. Minor concerns about unintentional/accidental risk to self. Minor ASB. Minor concerns about risk of abuse/exploitation from others/society

Definite indicators of risk of deliberate self- harm/suicide attempt. Definite indicators of unintentional/accidental risk to self.Risk to property and/or minor risk to physical safety of others. Definite risk of abuse/exploitation from others/society

High risk to physical safety as a result of deliberate self-harm/suicide attempt. High risk to physical safety of self as a result of self-neglect, unsafe behaviour or inability to maintain a safe environment.High risk to physical safety of others as a result of dangerous/criminal/offending behaviour

Immediate risk to physical safety of self as a result of deliberate self-harm or suicide attempt.Immediate risk to physical safety as a result of self-neglect, unsafe behaviour or inability to maintain safe environment.

Total score 0-11 LOWTotal score 12-24 MEDIUMTotal score 25 + HIGHA score of 4 or 5 in three or more of the above categories would indicate an individual experiences complex needs and requires a multi-agency approach

Total score

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Appendix 1 Client/Worker Action Plan

Action Person Responsible

Due Date

Outcome

Accommodation & related appointments/visits

Physical Health

Mental Health

Drugs and Alcohol

Finances/Benefits

What are you interests and hobbies? e.g. literacy and numeracy, life skills, art, computers skills, reading, fishing etc

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