KBOP Referral form

Please Fill in the form Below

Consent and Client Declaration Information – KBOP Please read out in full to the applicant

To be able to process your referral, we need to record, store and process details about your needs, housing and support. This may contain your personal data, and includes “special category data” such as information about your health, ethnicity, religion etc.

We ask for this information so that we can make a decision about whether our service is the best one for you, or whether there is a more suitable service elsewhere. We also use the special category data for monitoring purposes, to make sure our services are fair and easy to access, and to meet funding requirements. We will record your personal data on our secure electronic system and also on paper.

You don’t have to answer any question that you do not want to, and you should let us know if you don’t want to give us some of the information we ask for. However, this may affect our ability to provide you with an appropriate service.

We may contact other professionals and agencies who have knowledge of you currently or in the past (e.g. Health / Housing Professionals, Police, Probation). This is so we can get additional information about your needs, and so we are aware of any risks (e.g. Police check, landlord reference).

Further information can be found in our Client Privacy Notice, which is available on request or can be downloaded from our website

Declaration – Please ask the client to confirm the following;

  • You authorise Kirklees Better Outcomes Partnership to process your personal information for the reasons explained
  • You confirm that the information you provide will be correct and true to the best of your knowledge
  • You understand that your information may be shared with other agencies / professionals as previously explained
  • You acknowledge that you have been made aware of the Client Privacy Notice, which explains how your personal details will be managedConsent questions
    • Consent to hold uploaded files and process your data
    • Consent to include data in reporting
    • Consent to include data on secure test systems
    • Consent to share data with regulatory bodies – (i.e organisations in KBOP)
    • Consent to share data with essential partners – (i.e WYP, social care)

Alternative Form Download

If you do not wish to fill in the form below you can download the form and print it off and send it back to us by post.

Simply hit the button below to download the paper version of our form and fill in as much information as possible and send it back to us.

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Page 1 of 7

To be completed by the client, carer or agency

Client Approval

Applicant Details

Please add names and Date of Birth of each child

Support Needs

Commentary on Support Needs

This section of the form seeks to identify an individual need for the various services available under Kirklees Better Outcomes Partnership. The information obtained will enable us to ascertain the applicant’s eligibility on to program and determine the most appropriate provider to deliver the service.

Eg; access to housing, homelessness prevention, rent arrears, outstanding eviction, managing a tenancy, tenancy sustainment, independent living skills.

Eg; assistance with welfare benefits / sanctions, budgeting, managing debts, maximising income.

Eg; physical health, mental health and wellbeing.

Eg; drug, alcohol misuse.

Eg; compliance with statutory orders, managing risk to others.

Eg; personal safety, family, parenting, safeguarding.

Eg; employment, training, education and volunteering.

Eg; self harm, ASB, hoarding, safeguarding / protection from abuse.

Eg; community, other agency, relationships, parenting and caring, motivation and personal responsibility, self esteem.

Eg; recourse to public funds, immigration status, access to criminal / civil justice.

Involved Professionals, current or previous

Please give details of all other professionals, agencies and carers who are involved in supporting the applicant (use separate sheet if needed). This may include, for example, Welfare Rights Services, Drug Workers, CPNs, Doctors, Psychiatrists, Social Workers.

Hazards and Risks

Please mark with a tick any of the following which you think we should consider when working with this applicant.
We will contact you for further information if required, please provide your contact details in the final section.

Referrer Details

Please Print full name for signature

Please Print full name for signature