St Andrews Community Housing Association (SACHA) - Enfield, Edmonton, Haringey, Barnet and Tottenham.

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Referrals

1. Introduction

As part of our quality control procedures, before any placement can be considered, our referral form must be completed and sent to our Assesments Team. Once the information has been assessed and any questions answered, only then can a decision be made whether the placement can be progressed, particularly in the case of Service Users with higher support needs.

There are two ways to send us a referral form.

You can click on the icons below to print out the form, then simply fill it in and return it to us by post to; Oak Tree Care Services, Referrals Officer, 62-64 Bounces Road, London N9 8JS.

	Date: 22-01-12	Name: SACHA-REFERRAL-FORM.pdf	Size: 114kb
	Date: 22-01-12	Name: SACHA-REFERRAL-FORM.doc	Size: 83kb

You can complete the electronic form below, then click the large SEND NOW button at the bottom of the form, which we will then receive automatically via email.

Important Information
Please complete the below form in as much detail as possible.
Todays Date:	... this is automatically entered and cannot be changed
Reference:
Client Full Name:	*required
Service Required:
Date Of Birth:
Social Worker:
Social Worker Email:
Social Worker Contact No:
Placing Authority:
Placing Authority Contact No:
Placing Authority Address:
Placement Start Date:
Projected/Actual End Date:
Client Status (i.e. Minor etc)
National Insurance No:
Childrens Act Section:
Immigration Status:
Solicitor Name:
Solicitor Address:
Solicitor Contact No:

Service Fee Details
Please complete this section in FULL...
Weekly Accommodation Fee:
Daily Accommodation Fee:
Supporting Hours Per Week:
Subsistence Per Week:
Purchase Order No:
Authorised By:	*required
Your Email Address:	*required
Contact Number:
Invoice Address:

Client History

Please supply the following information in as much detail as possible.

1. Family:

2. Past/Current Placements:

3. Reasons for Placement Request:

4. Health Status

5. Education/Employment:

6. Racial & Cultural Background:

7. Interests & Hobbies:

8. Past Incidents of Violence/Damage:

9. Criminal Record:

10. Pending Cases:

11. Benefits or Income:

12. Specific Requirements:

13. General Comments:

When complete please click the SEND NOW button to email the form to us now ---->

St Andrews Community Housing Association (SACHA) is regulated by the Homes & Communities Agency. Registration Number L4546