Resident name: Date of birth:
Address: (including postcode)
Contact number:
Email address:
Who lives at the property with you?
Name: Date of birth:
Name: Date of birth:
Name: Date of birth:
DIRECT SUPPORT
Support to prevent the
risk of Homelessness
Budgeting and Debt
Management
Independent living skills
(form filling and phone
calls)
Maximising Income
(claiming benefits)
Support setting up rent
and utility payments
Applying for grants and
funding
Address housing arrears
Registering with Health
Services
Setting up a new home
GENERAL INFORMATION & SIGNPOSTING
How to register for
housing
Accessing social,
leisure, religious and
cultural activities
Employment, education,
training and volunteering
REFERRAL SERVICE
First Contact Plus
(including accessing aids
aids and adaptations)
BDC Domestic Abuse
Services
BDC Childrens Workers
Referrals to Social Care
for Children or Adults
Substance Misuse
Services
Accessing other
specialist services
(Please specify in the
reason for referral
section of this form’)
Mental Health Services
SUPPORT SERVICES WE OFFER:
(Tick as many boxes as required)
Referral for
Resident Support
DD YYYYMM
DD YYYYMM
DD YYYYMM
DD YYYYMM
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WHAT OTHER AGENCIES ARE INVOLVED?
AGENCY NAME: CONTACT NAME AT THE AGENCY TELEPHONE NUMBER:
COMPLETED BY
NAME: (PLEASE PRINT)
POSITION HELD:
AGENCY:
CONTACT NUMBER:
REASON FOR THE REFERRAL: (include any health conditions they have)
PLEASE SIGN TO SAY THAT YOU HAVE GAINED THE PERSONS PERMISSION FOR THIS REFERRAL
Please send the completed form to residentsupport@blaby.gov.uk
or post to: Resident Support Services, Blaby District Council,
Desford Road, Narborough, Leicestershire, LE19 2EP.
SIGNED: DATE:
DD YYYYMM
/ /
click to sign
signature
click to edit
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