Hostels In-Reach: Referral Form
Share the client’s details and the referral reason, goals, and support needs.
Who is the referral for?
*
Myself
Someone else
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Referrer Information
Referrer Name
*
First Name
Last Name
Phone Number
Email Address
example@example.com
Relationship to Resident
e.g., Keyworker
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Resident information
Name
*
First Name
Last Name
Preferred Name (If Any)
Pronouns
She/Her
He/Him
They/Them
Other
Hostel Residence
*
Please Select
88 Arlington Road (SHP)
220 Arlington Road (Riverside)
Birkenhead Street (St Mungo's)
Cambria House (Salvation Army)
Conway House (Saphire Independent Housing)
Dennis Handfield House (SHP)
Endell Street (St Mungo's)
Endsleigh Gardens (St Mungo's)
Grace House (SHP)
Holmes Road (LB Camden)
Mount Pleasant (LB Camden)
No.9 (SHP)
North Villas (LB Camden)
Southampton Row (SHP)
St Mungo's Shared Houses (various addresses)
Other
We may be able to consider other hostels or addresses
If Other, please give an address
Phone Number
*
Please enter the best phone number for us to contact the resident.
Email Address
example@example.com
Key Contact at Hostel
example@example.com - If different to referrer
Language
Please select or write down the language the resident feels most comfortable communicating in.
Preferred Method of Contact
Phone call
Text
Email
In person
GP Practice & Key Contact
Camden GP & (if applicable) Main Doctor
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Reason for Referral
*
Goals/Focus
Current Services Engaging With
Reasonable Adjustments / Support Needs
Any Further Information
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Demographic Information
All questions in this section are completely optional. We ask them to help us make sure that we are doing our best to make our services available to all.
Ethnicity
Please Select
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Bangladeshi
Asian or Asian British: Chinese
Any other Asian background
Black or Black British: Caribbean
Black or Black British: African
Any other Black, Black or Black British background
White or White British: English, Welsh, Scottish, Northern Irish, or British
White: Irish
White: Gypsy or Irish Traveller
White: Roma
Other ethnic group: Arab, Scottish Arab or British Arab
Mixed or multiple ethnic groups: White and Black Caribbean
Mixed or multiple ethnic groups: White and Black African
Mixed or multiple ethnic groups: White and Asian
Any other Mixed or multiple ethnic background
Gender Identity
Please Select
Woman
Man
Non-binary
Agender
Intersex
Other
Sexuality
Please Select
Straight or Heterosexual
Gay or Lesbian
Bisexual
Pansexual
Asexual
Queer
Any other sexual orientations
Religion
Please Select
No religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other religion
Do you consider yourself to have a disability? If yes, please tell us more about this below.
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Please confirm whether the resident has been informed of the referral and agreed to it.
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