Floating support online referral form

1 Start 2 Complete

The majority of requests for support are received in the form of referrals from other organisations.

However, you can also refer yourself using our online form below.

Alternatively, you can download the SUSTAIN Referral Form and send this to us at:

Homes Plus

Supported Housing

Brassey Rd

Old Potts Way

Shrewsbury

SY3 7FA

We can accept referrals for housing support for anyone over the age 18 in any tenure who lives in the Shropshire Council area. The referral will be passed onto the most relevant provider within the Sustain consortium based on the area the client lives. Please note: we are not currently accepting referrals for anyone outside of the Shropshire Council area such as residents of Telford and Wrekin.

Person needing support

Name *

Date of birth *

Month

Day

Year

Telephone number *

Gender

Address *

Area *

Post code

Email address

In receipt of benefits *

Yes

Employment status *

Is this a self-referral? *

Yes

Referrer information

Name of referrer *

Referring agency *

Telephone number *

Email address

Reasons support is being requested

Please briefly describe the reasons support is required (please also include details of any risks, important dates you would like us to take into account e.g. court dates, special needs or requirements e.g. female support worker) *

Data protection

The person named on this form must be aware of this referral and give permission to share this information with relevant agencies relating to this referral.

We’ve updated our privacy notice

We’ve made some important changes to our privacy notice. To find out more, visit our data protection pages.

Care Plus Staffordshire Ltd.

Registered Office: Acton Court, Acton Gate, Stafford, Staffordshire ST18 9AP

We are registered as a Charitable Industrial & Provident Society (30948R)

Registered with the Care Quality Commission (2000032662)

VAT Number: 135 5241 33

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Floating support online referral form

Person needing support

Referrer information

Reasons support is being requested

Data protection