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Liverpool MainStay Assessment Form

General information

1.0 Circumstances

1.1 Reasons for assessment: *o First presentation to MainStay serviceso Repeat presentation to MainStay serviceso Person needs a service that provides for higher

support needso Person needs a service that provides for lower

support needso Person is being evicted or has just been evicted

from a MainStay service

o Person wishes to leave current serviceo Person will not engage with current serviceo Person a risk to or from a known person(s)

within the current service (please specify in the box below)

o Other (please specify in the box below)

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Details of current housing situation and reasons for assessment: *

Applicant’s surname*:Applicant’s forename*:Also known as:DOB*:N.I NoEthnicity*:Religion or Beliefs*:Sexual Orientation*:Does the client consider themselves transgender?*Is the applicant ex-Armed Forces personnel?Next of Kin details*: Name:

Address:

Contact Number:Applicants contact number:

2.0. Accommodation History

2.1 Can you give me your last 5 years accommodation history? (Where possible please provide name of landlord within the address field)

From Up to Address Tenure type Reason for leaving

Name Accommodation Provider

Contact type Phone Email From To

2.2 Please provide any contact details for accommodation providers

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2.3 Are you currently rough sleeping? *Yes o No o

2.4 Have you previously rough slept? * Yes o No o

2.5 Are you currently registered on Property Pool Plus? Yes o No o

If yes which office did you register with?

o Knowsley Housing Trust o Property Pool Plus Wirral o Sefton One Vision Housing o Halton Housing Trust o Your Homes Liverpool o Cobalt Housing Liverpool o Cosmopolitan Housing Liverpool o Liverpool Mutual Homes

o Liverpool Housing Trust o Pierhead Housing Association Liverpool o Plus Dane Group Liverpool o Regenda first Liverpool o Riverside Liverpool o South Liverpool Housing o Venture Housing Liverpool

2.6 What support needs do you have in this area? Accommodation History (any additional information)

3.0 Local Connection

3.1 What Local Authority do you have a local connection with? (This question is based on the information received from accommodation history) *

Halton o Knowsley o Liverpool o Sefton oSt Helens o Wirral o Other Authority o

3.2 Within the last five years, how long have you lived in the authority stated above?

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Further details:

Please give details, including if you have lived in any other areas:

If yes please state when current period of rough sleeping started:

* If the client has been able to prove their local connection sufficiently after answering this question then you can move on to the question where the assessor must decide the local authority the client has a connection with *

3.3 Do you have any close family associations that have lived in the authority stated above for at least 5 years? (Close family usually includes father, mother, brothers, sisters, and children)

3.4 Does the person have special circumstances for needing to reside in the authority stated above?

4.0 Economic and Legal Status

4.1 Are you a British Citizen? * Yes o (if yes continue to 4.7) No o (if no please continue to 4.2)

4.2 Are you a member of a country within the European Economic Area? Yes o No o (If no please go to 4.3)

4.3 Date of arrival to the UK?

4.4 Have you got a continuous claim for JSA and Housing Benefit within this authority starting before the 31st March 2014? Yes o No o

4.5 Have you been granted leave to remain in the UK? Yes o No o

4.6 Can the person provide evidence of their leave to remain? (Please secure and upload any evidence to support this) Yes o No o

*Please contact Asylum Link - St Anne's Centre, 7 Overbury Street, Liverpool L7 3HJ Telephone: 0151 709 1713 or Refugee Action - 64 Mount Pleasant, Liverpool L3 5SD Telephone: 0151 214 3020*

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If yes please state which country:

Further details:

Further details:

Please specify:

4.7 Are you entitled to public funds?* Yes o No o

4.8 Are you currently in receipt of or awaiting a claim for benefits? *

Yes o (If yes please complete below) No o (if no continue to 4.9)

Type of benefits Claim Status Weekly amount?

If awaiting claim; date of claim

Job Seekers AllowanceEmployment and Support AllowanceIncome SupportIncapacity BenefitDisability Living AllowanceState PensionStatutory Sick PaySevere Disablement AllowanceDisability Working AllowanceWorking Tax Credits

4.9 Do you receive any other income? Yes o (If yes please complete below) No o (if no please continue to 4.10)

4.10 What support needs do you have in this area?-Economic & Legal Status (any additional information

5.0 Physical Health

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Further details:

Other income received What is the weekly amount of additional income received?

Working for an employer Self Employed Government training Occupational Pension Student Funding Other (please specify) Working for an employer

5.1 Do you have any current health issues or are you receiving any treatment for your health? * Yes o No oIf yes please state below

5.2 Have you had any serious health issues or been admitted to hospital in the last 5 years? Yes o No oIf yes please state below

5.3 Do you have a GP? * Yes o No o Don’t know o

5.4 Who is your GP? *

5.5 Are you being prescribed any medication for any physical health conditions? * Yes o No o

If yes please state below

5.6 Can you manage your medication or do you need support with this? Yes o No o

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Further details:

Further details:

Further details:

Prescribed medication list

Details of medication How long have you been taking this medication? Prescribed dosage

5.7 Do you have any allergies? Yes o No o

If yes, please fill in table below as appropriate

What are you allergic to? Are there any further instructions that we should be aware of if you have an allergic reaction?

5.8 Do you have any mobility problems? * Yes o No o If yes please state below

5.9 Do you have any hearing difficulties? Yes o No o


5.10 Do you have any problems with your eyesight? Yes o No o If yes please state below

5.11 Do you require any aids or adaptations within your accommodation? * Yes o No o (if no continue to 5.13)


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Further details:

Further details:

Further details:

5.12 Does the applicant require a mobility accessible room? Yes o No o

5.13 What support needs do you have in this area?- Physical Health (Any additional information including immediate physical health needs)

6.0 Emotional and Mental Wellbeing

6.1 Do you currently, or have you ever had any mental health issues? * Current o Previous o No o (if no continue to 6.4)

Please fill in table below as appropriate. Mental Health Conditions Further Details Current or

Previous

Depression

Anxiety

An Eating Disorder

Bipolar

Obsessive Compulsive DisorderPersonality Disorder

Phobias

Post Traumatic Stress DisorderPostnatal Depression

Psychosis

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Further details:

Further details:

Seasonal Affective Disorder

Schizophrenia

Other (please specify)

6.2 Have you ever been assessed by a psychiatrist? ( If possible please record contact details) Yes o No o If yes please state below

Please provide contact details for any mental health professionals or services

Name Organisation/Address Contact type Phone Email From To

6.2 Have you ever spent any time in hospital for your mental health condition? Yes o No o If yes please state below

6.3 Have you been prescribed medication for your mental health condition? Yes o No o If yes, please fill in table below as appropriate

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Further details:

Further details:

Medication Currently prescribed?

If currently prescribed what is the dosage?

If currently prescribed when did you take last?

6.4 Have you ever attempted to take your own life?* Yes o No o If yes please state below

6.5 Have you any suicidal thoughts currently?* Yes o No o If yes please state below

6.6 Have you ever tried to self harm? * Yes o No o If yes please state below

6.7 What support needs do you have in this area? - Emotional & Mental Wellbeing (Any additional information or details of any triggers)

7.0 Alcohol

7.1 Do you drink alcohol? * Yes o No o (if no continue to 7.2)

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Further details:

Further details:

Further details:

Further details:

If yes when was your last drink?

Please complete the alcohol consumption chart below for current alcohol use.

7.2 How often do you drink?

o Daily o 4 or more times a week o 2-3 times per week o Weekly o Occasionally

Alcohol consumption chartWhat do you drink? Amount consumedStrong beer

Strong cider

Cider

Beer

Spirits

Alcopops

Wine

Other (please specify)

You can complete more than one box

7.2 Has any harm been caused as a result of your drinking? (How does drink affect you)

7.3 Have you ever been a street drinker? Yes o No o

7.4 Have you had any problems with alcohol? * Yes o No o (if no go to 8.0)If yes please state below,

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Please specify:

7.5 Have you ever been in treatment for your alcohol use? Yes o No o If yes, please fill in table below as appropriate

What treatment? Date from Date to Outcome of treatment (state if current) If other treatment selected please specify?

Counselling

Outpatients

Residential

Detox only

Inpatient

Community Detox

Prescribing

Day Treatment

Other please specify

Please provide any contact details of any services that have helped you with your alcohol use


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Further details:

7.6 What support needs do you have in this area? - Alcohol (Any additional information including effect on day to day life, triggers)

8.0 Drugs

8.1 Have you ever used any drugs? * Yes o No o (If no continue to 9.0)

8.2 Are you presently using any drugs? Yes o No o

Drugs Current or previous use?

Frequency?-Daily-2-3 times p/w-4 or more times a week-Weekly-Occasionally

Amount used?

How long have you been using?

When last used? Method of use?-Swallowing-Smoking-Snorting-Rectal-Injecting-Other please specify

Amphetamines

Barbiturates

Benzodiazepines

Cannabis

Cocaine

Crack

Crystal Meth

Ecstasy

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Further details:

Heroin (opiates)

Ketamine

Legal Highs

Drugs Current or previous use?

Frequency?-Daily-2-3 times p/w-4 or more times a week-Weekly-Occasionally

Amount used?

How long have you been using?

When last used? Method of use?-Swallowing-Smoking-Snorting-Rectal-Injecting-Other please specify

Librium

LSD

MDMA

Methadone

Prescribed medicationSolvents

Steroids

Subutex

Other

8.3 Have you ever been in treatment for your drug issues? Yes o No o

If yes, please fill in table below as appropriate

What treatment? Date from Date to Outcome if relevant (state if current)

Other information please specify?

Counselling

Outpatients

Residential

Detox only

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Inpatient

Community Detox

Prescribing

What treatment? Date from Date to Outcome if relevant (state if current)

Other information please specify?

Day Treatment

Other please specify

8.3 Do you currently have any services supporting you with your drug use? Yes o No o If yes please state below

8.4 Have you previously had any services supporting you with your drug use? Yes o No o If yes please state below

8.5 Please provide contact details of any workers or services that have helped the applicant with their drug use.


8.6 Does the applicant display any indicators for risk of overdose? Yes o No o If yes please provide more detail regarding the area of risk.

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Further details:

Further details:

Further details:

8.7 What support needs do you have in this area? (Any additional information include effect on day to day life, triggers, periods of abstinence)

9.0 Offending history

9.1 Do you have any criminal convictions? * Yes o No o (if no continue to 9.12)

9.2 What was your most recent conviction for?

9.3 Have you ever been convicted of any offences concerning the following?

Violence Yes o No o Domestic Violence Yes o No o Arson Yes o No o Sexual Offences Yes o No o Offences against persons under the age of 18 Yes o No o Offences involving weapons or fire arms Yes o No o

9.4 Please tell me about any other previous convictions? (please consult guidance manual regarding recording of offences)

Name of offence Further details of offence When did Sentence received

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Further details:

Please specify:

If yes to any of the above please give further details:

offence occur?

Name of offence Further details of offence When did offence occur?

Sentence received

9.5 Is any of this offending linked to substance misuse? Yes o No o

9.6 Are you currently on an order or licence? Yes o (if yes continue to 9.7) No o

9.7 If yes what type of order are you on? (please include any restrictions)

9.8 When does this order expire?

9.9 Do you have an offender manager (probation officer/case manager)? Yes o No o

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9.10 Please provide contact details of applicant's offender manager or any related offending services involved with the applicant


9.11 Are you subject to any Multi Agency Public Protection Arrangements (MAPPA)? Yes o No o If yes please state below

9.12 Do you have any outstanding charges or court cases pending? * Yes o No o(if no continue to 9.13) If yes please state below

9.13 What support needs do you have in this area? - Offending History (Any additional information)

10.0 Life Skills

10.1 Have you ever had rent arrears or problems with debt? Yes o No o (if no go to 10.2)If yes please state below

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Further details:

Further details:

Further details:

Further details:

10.2 Have you ever had problems with gambling? Yes o No o (if no continue to life skill needs) If yes please state below

Life Skill needs Please provide further details if person has any support needs in these areas, if not leave blankLife skills needs

Budgeting

Cooking

Shopping

Memory or remembering things?Personal Hygiene (bathing, washing)

Keeping home clean and tidy

Cleaning laundry

Literacy

Numeracy

Filling in forms

Verbally communicating

Isolation

Anti-Social Behaviour

Social Interaction

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Further details:

11.0Meaningful Use of Time

11.1 Are you currently involved in any education or training? * Yes o No o (if no go to 11.3) If yes please provide detail’s belowWhat are you doing? Where did you do this? If other please specify where

11.2 Do you feel ready to engage in education, training or employment? Yes o No o

11.3 Do you have any cultural needs? Yes o No o If yes please state below

12.0Vulnerability

Please consult the guidance manual for further information about answering this section

12.1 Does the applicant have any history or indicators of vulnerability?

12.2 Are there any specific persons you cannot be accommodated with?

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Further details:

If yes what would you like to do:

13.0Family/Relationships

13.1 Do you have a partner? Yes o (if yes go to13.2) No o (if no go to 13.3)

13.2 Are you looking for accommodation together? (please record name of partner in support needsYes o No o Name of Partner

13.3 Do you have any children? Yes o No o If yes please state below

13.4 What support needs do you have in this area? - Family & Relationships (Any additional information)

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Name of child Age of child

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Further details:

14.0 Risk Summary

Risk

Non

e

Low

High

Very

Hi

gh

Comments

Alcohol*

Drugs*

Mental Health*

Physical Health*

Suicide*

Self Harm*

Offending*

Violence*

Arson*

Sexual Offences*

Offences against persons under 18*

Financial*

Family/Relationships*

Accommodation Breakdown*

Vulnerability*

15.0 Needs Section Summary

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Please include comments for medium to high needs and ensure all questions have been answered.

Needs

Non

e

Low

High

Very

Hi

gh

Comments

Motivation and Taking Responsibility

Self Care and Living Skills

Managing Money

Social Networks and Relationships

Drugs and Alcohol misuse

Physical Health

Emotional and Mental Health

Meaningful Use of Time

Managing Tenancy and Accommodation

Offending

16.0 Matching questions

16.1 Please confirm the Drug and Alcohol Needs?* None o Low o Medium o High o

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If high the following questions will appear, if not continue to question

16.2 Is the applicant better suited to a harm reduction or abstinence substance misuse service rather than a Young Peoples Service? Yes o No o

16.3 Is the applicant currently abstinent?* Yes o No o

16.4 Is the applicant unable to live independently with low level support because of Substance Misuse issues?Yes o No o

16.5 Would the applicant like to access Liverpool-based residential rehabilitation to help them overcome their substance misuse? Yes o No o

If client states yes to this answer then please explain that in order to access rehabilitation they will need to be substance free on the day of entry, if they require a detox they can be given direction around this during their Park View assessment.

17.0 Additional Needs

17.1 Is there a specific reason why the person needs accommodation specific to their gender?* Yes o No o If yes please give details

17.2 Based on the persons' previous accommodation and motivation do you feel they would be suitable to live independently with low level support? Yes o No o

17.3 Do you feel the applicant would be better suited to Supported Lodgings with structured support rather than a hostel/foyer based service? Yes o (if yes continue to 19.4) No o

17.4 Does the applicant wish to live in supported lodgings with structured support rather than a hostel or foyer based? Yes o No o

18. 0 Applicants assessed Housing status Housing Status

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Comments:

Assessed MainStay Housing Status*:

o Override=1 (MainStay team only)o Statutory homeless =2 (Housing Options teams only)o Entrenched Rough Sleepers=3 (Whitechapel staff only)o Rough Sleeper=4 (Whitechapel and Basement staff only)o In danger of rough sleeping=5o No access to settled accommodation=6o No permanent accommodation=7

For those rough sleeping please explain that the location is needed to confirm their rough sleeping status. In order to keep their rough sleeper status they must continue to present at the Whitechapel (regularly) or have their rough sleeping status confirmed by the Outreach teams

Please insert the relevant priority number as shown next to each housing status *

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This assessment is subject to change

If you find something is incorrect or missing please let us know by emailing [email protected]

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mailto:[email protected]

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