Warwickshire Referral Form

Welcome to P3’s floating support service for over 25’s. We provide Support for people to live independently in their homes including advice and information on maintaining tenancies, dealing with debt and staying independent. If you would like to refer someone for support or need support yourself then please complete the online form. If you need support with your referral please call Freephone 0808 164 6220

Who are you making a referral for?

Myself Someone Else

Do TheyYou live in Warwickshire?

Yes No

Are theyyou aged 25 years or over

(or approaching 25 within the next 6 months)?

Yes

Please enter theiryour date of birth in the box below

Do any of the following apply?

They areI am homeless Or sleeping rough Or sofa surfing They areI am at risk of eviction and/or re-possession and/or becoming homeless TheyI have a large amount of debt which may affect theirmy housing situation (i.e. ability to pay rent/mortgage/bills) TheyI don’t feel safe where theyI live Or They areI am being harassed Or They areI am experiencing harm TheyI have difficulties understanding what is said to themmeOr TheyI struggle to understand and process information Or TheyI find information overwhelming TheirMy health needs are impacting theirmy ability to maintain a tenancy – disability Or mental health Or substance misuse NoneOr Not sure

Referrer Details

Your Details

Please enter your email address/phone number or another way we can contact you below

Please enter your full address or where we can find you below

Client Details

Please enter their name below

Please enter their email address/phone number or another way we can contact them below

Please enter their full address or where we can find them below

Tenure

Please choose the option below that best describes theiryour housing situation (if any).

Communication preferences

How would theyyou prefer to be contacted?

Please enter theiryour preferred language below

Do theyyou consider themselvesyourself disabled?

Yes No

Next of Kin Details

Please enter an email address/phone number or another way we can contact them below

Please specify your relationship with them (e.g partner)

Agency Involvement?Do you have support from anyone?

Doctor Psychiatrist Community Psychiatric Nurse Dentist Social Worker Drugs / Alcohol Agency Other

Support Needs & RiskSupport needs

Please select all that apply and provide further information

Mental health Physical health Criminal Convictions Safeguarding Alcohol or Drug issues Not sure / None of the above

Is there any other information you would like to provide?

Data Consent

If a different local service is identified as being more suitable for your housing needs or support requirements, P3 will automatically transfer your referral to them on your behalf. Please click the accept button below to provide us with your permission to do this. If you are submitting a referral on behalf of somebody else, please click the accept button below to confirm they give their permission.

Click here to accept