Online Referral Form

Doorway has a Young Person's Service for young people aged 16-18 years old. If you are referring someone who is in this age group please indicate: Yes No

Name

Age

Date of Birth (DD/MM/YYYY)

Male/Female Male Female

NI Number

Current/Contact Address

Telephone

Mobile

Type of accommodation occupied by Young Person prior to being referred to Doorway: Local Authority tenant H Assoc tenant Staying with friends Other temp accommodation Rough Sleeping Foster care Direct access hostel Living with family Resident Landlord Prison Private tenant Supported Housing Probation hostel Other (Please specify below)

Other:

Has the applicant had any previous contact with Doorway? Yes No

Name

Address

Telephone

Mobile

Are you aware of any other professional organisations that are working or have worked with the client?
If so, please advise (e.g. Connexions, Fusion, Probation, Community Drugs Team):

Income source of applicant: Income Support FT Student PT Student JSA Training Allowance FT Work PT Work New Deal DLA/ICA Zero Income Other (Please specify below)

Other:

Has the applicant any current or previous convictions? Yes No

Details:

Is the applicant currently or have they ever been on probation? Yes No

Details:

Is the applicant currently or have they ever been in care? (eg. Foster Care) Yes No

Details:

Names of any Social Worker or Probation Officer if applicable:

For the purpose of Equal Opportunities, please tick the appropriate box. This section has no effect on the referral process or subsequent interviews.

Ethnic Origin: White - British White - Irish White - Other Mixed - White/Black Caribbean Mixed - White/Black African Mixed - White/Black Asian Mixed - Other Asian - Indian Asian - Pakistani Asian - Bangladeshi Asian - Other Black - Caribbean Black - African Black - Other Chinese Ethnic Group not known/refused

I consent to the disclosure of information to Nuneaton and Bedworth Doorway, and that Nuneaton and Bedworth Doorway might seek further information from my referring agency or other outside bodies as required.

Tick this box to confirm the declaration above: