Name (if known):

Mobile telephone number (if known and willing to provide):


Age Please indicate approximate one
16-20: 21-30: 31-40: 41-50: 51-60: 60+:

Ethnicity:


Gender
Male: Female: Unknown:

Hair (Long, Short, bald, colour, facial hair, other):


Approximate height:


Other Identifying features


Location
Name of street and full description of sleeping site (e.g. shop doorway, under bridge, stairwell of block of flats etc). If you are unsure of the exact location, please provide as much detail as possible.


Length of time at this location (If Known):


What times are they usually here? :


Are you aware of any risks that this person may cause to themselves or other individuals? (Please indicate your answer)
Yes: No: Don't know:

If yes, who might they pose a risk to: (please indicate your answer)
Themselves: Other individuals:

Please give any information that will be helpful for professional staff to safely contact or approach the individual:


Is the person who is sleeping rough aware you are making this referral? (Please indicate answer)
Yes: No: Don't know:

Are you aware of any specific support needs? (Please indicate)
Drugs/Substance: Alcohol: Mental Health: Health: Elderly: Young:

Your contact details (optional)
Name:

Organisation/Agency:

Your contact number:

Your email address:


We will only use your details if we require more information from you.

Thank You