Lamplight API response

Address 4

Address 5

Postcode

Email address

Mobile phone

Phone number

Is it safe to contact you in the following ways?

By post

By email

By mobile

By text message

Tick this box if you wish to receive information about Alana House activities and events for service users

If not safe to contact on the above address, please provide an alternative contact address:

If not safe to contact on the above phone number, please give details here:

Location

Please tell us which area you live in.

(We are currently only accepting self-referrals from Reading. You must live in Reading to be able to access support from Alana House. If you are unsure, please call Alana House on 0118 921 7640.)

Location

Personal details

Please provide further details about yourself.

Date of birth

Gender identity: Which of the following options best describes how the person being referred thinks of themselves?

Gender identity: Is the gender of the person being referred the same as the gender they were given at birth?

Does the person being referred consider themselves to have a disability?

If yes, are any reasonable adjustments needed to support a visit to Alana House? Please give details

Details of disability

Ethnicity

If you selected other ethnic group, please give details here:

Nationality (Passport held)

If the individual being referred has No Recourse to Public Funds (NRPF), please select this option below; if you are unsure, please leave this field blank

Current support needs

Please tell us why you would like support from Alana House. Use the sections below to give as much detail as possible about how you hope Alana House can support you:

-- ACCOMMODATION --

Details - Homeless? Moved area? Tenancy issues?

-- EDUCATION, TRAINING AND EMPLOYMENT --

Details - Unemployed? Need new skills? In education/training?

-- PHYSICAL HEALTH --

Details - Any disabilities or difficulties?

-- MENTAL HEALTH --

Details - Diagnosis? Medication?

-- DRUGS AND ALCOHOL --

Details - Any concerns with drug or alcohol use? How often? Which substances?

-- FINANCE, DEBT AND BENEFITS --

Details - Any financial problems? Receiving benefits?

-- CHILDREN AND FAMILY --

Details - Any Child in Need/Child Protection plans? Children adopted/fostered? Court proceedings?

-- ATTITUDES, THINKING AND BEHAVIOUR --

Details - Past offending behaviour? At risk of offending? Any contact with the criminal justice system?

Is the individual on probation? (If the answer is yes, please tick this box)

If the individual is on probation, please provide the Probation Officer's details below:

Name of Probation Officer

Probation Officer email address

Probation Officer phone number

-- EXPERIENCE WITH DOMESTIC VIOLENCE, ABUSE OR RAPE --

Details - When? Known perpetrator? Relationship to victim? Experience with stalking?

-- SEX WORKING/EXPLOITATION --

Details - Any past or current involvement with sex work?

Involvement with other organisations

If you are involved with any other agencies, please give their details here:

-- ORGANISATION 1 --

Name of organisation (1)

Name of contact person at this organisation (1)

Contact person's job description (1)

Contact person's phone number (1)

Details of the involvement with this organisation (1)

-- ORGANISATION 2 --

Name of organisation (2)

Name of contact person at this organisation (2)

Contact person's job description (2)

Contact person's phone number (2)

Details of the involvement with this organisation (2)

-- ORGANISATION 3 --

Name of organisation (3)

Name of contact person at this organisation (3)

Contact person's job description (3)

Contact person's phone number (3)

Details of the involvement with this organisation (3)

If there are any other organisations involved with the individual not mentioned above, please give details here

Any other relevant information

Any learning difficulties? Communication difficulties? English as a second language?

Any other information you would like to give?

Risk assessment

We need to ask about any risks that we need to be aware of and address when working with the person being referred. This will allow us to think about the best way to support everyone safely.

Please include details of any history of self-harm, violent or threatening behaviour, risks to staff and substance misuse.

It would be helpful if you could include any information of how any of these risks are currently being managed.

Risk to self

If risk to self is medium or high, please provide details here:

Risk to a known adult

If risk to a known adult is medium or high, please provide details here:

Risk to the public

If risk to the public is medium or high, please provide details here:

Risk to children

If risk to children is medium or high, please provide details here:

Risk to staff

If risk to staff is medium or high, please provide details here:

Is the person being referred at risk from others? If yes please give details

Does the person being referred feel they are at risk of offending? If yes please give details

Data protection and information sharing

In submitting this form, the individual being referred agrees that the information contained within can be held securely at Alana House for the purposes of proceeding with support as outlined in the Alana House Privacy Notice.

A link to the Alana House Privacy Notice can be found at the bottom of this form.

Please confirm you agree to Alana House storing the data in this form as outlined in the Alana House Privacy Notice

If the referral doesn’t proceed we will delete all data given within 6 years from the date the decision was made to decline the referral.

How we store information and how we use data will be discussed with the individual being referred during their first meeting at Alana House. Further consent for their data to be stored will be sought.

Referral details

Please select the option 'self-referral' from the dropdown below

You can read our privacy policy here

Alana House self referral form

Other information

Location

Personal details

Current support needs

Involvement with other organisations

Any other relevant information

Risk assessment

Data protection and information sharing

Referral details