Derbyshire Independent Living Service Referral Form

Our service is funded specifically to support people with a mental health need.

Mental Health Needs:
Do you (or the person you are referring) have a mental health need which is impacting on your ability to manage in day-to-day life?

Please select the option that applies

Please select the applicable option:

Is there an immediate risk of homelessness (within 7 days)?

Are you (or the person being referred) fleeing domestic abuse?

Are you (or the person being referred) fleeing modern slavery?

Are you (or the person being referred) being discharged from hospital?

Please enter an estimated discharge date

This helps us ensure we ask you the right questions throughout this referral questionnaire.

Who are you making a referral for?

Please confirm you have the appropriate authority and consent to share the clients details with us for the purposes of providing them a support service. You must have this before you continue.

To confirm, please click the below button.

If you have previously received support from us, we can review previous records (only with your consent) to ensure we can pick-up from previous support provided.

If you have received support from another organisation, we may be able to work together with them to get the best result for you. This may depend on when you received past support and whether it is still relevant to what you need now.

Have youthey ever been referred to P3 or another Housing Related Support service before?

P3 is a proud signatory of the Armed Forces Covenant. This helps us tailor our support offer to your circumstances and history. Ex-forces personnel may be eligible for support services and facilities specifically for individuals who have served.

Have youthey ever been a member of the forces?

We use this information to ensure the correct provision is allocated to you and to confirm your eligibility for support.

In which local authority area are youthey currently residing,
or looking to reside?

We are only able to provide support to adults aged 16 and over. If you/they are very nearly approaching their 16th birthday, you may still proceed with the referral and they will become eligible for support once they reach aged 16.

We use care leaver information to ensure the support offer is tailored to individual needs and requirements

Please confirm your age range.the age range of the person you wish to refer.

Are you a Care Leaver?Is the individual a Care Leaver?

Please select all options that apply to yourtheir circumstances.

We use this information to establish how best we can help you, and to ensure you meet the eligibility requirements to receive support from our service. This information is also used to allow us to prioritise your case based on the information and circumstances you provide.

We use your name in order to address you when responding to or contacting you about your referral.

We use your relationship to the individual information to monitor the sources of our referrals and to ensure we are aware of you as a key contact for the individual being referred.

We use organisation information to monitor the sources of our referrals and to help us contact you if we need to.

We use contact information to keep you informed about your referral, and/or to contact you to clarify or discuss any information you may have provided.

We use risk information to ensure our staff are fully aware of any circumstances that may require us to take appropriate steps to ensure the safety of our employees.

Referrer Details



We use your name in order to address you when discussing your referral and any future correspondence or communication in relation to your support

Our service is for Adults aged 16 or older. We use date of birth information to validate your eligibility for this service.

You don’t have to tell us your gender, and it won’t affect the level of service we provide, but it helps us make sure we’re providing an inclusive service to everyone

We use contact information to make contact about the assessment and support.

YourTheir Details

YourTheir date of birth

Please enter yourtheir D.O.B in the boxes below

YourTheir gender

We need to know how we should make contact, and whether there are any communication restrictions we should know about.

What is yourtheir best contact? Please provide one or more of the requested contact details:

Set your contact preferences

Let us know which types of communication youthey are happy for us to use.



Email Post

We use accomodation status information to establish how best we can help you.

We use address and location information to ensure we can locate you when providing support, and to verify your residential status in Derbyshire.

YourTheir accommodation status:

YourTheir full address / current residence.

You have selected an option indicating you do not have a fixed address. Please provide a description of yourtheir location so we can make contact, or an address to which we can send correspondence.


We use language preference information to ensure we communicate with you in the correct language, and that you understand any documentation or conversations that we may have

We use accessibility needs information to ensure we can adapt our service, support, and contact arrangements to fit any accessibility requirements you may have.

Preferred Language

Do theyyou have any accessibility or communication needs?

We use this information to allow us to understand what it is you need help with, and to ensure we can correctly prioritise you if a waiting list is currently in operation.

Their CircumstancesYour circumstances

Please select any other circumstances that currently apply

We use this information to allow us to understand the reasons behind the need for support from our service.

Please briefly explain the main reason(s) you feel support is needed:

We use this information to allow us to plan future support requirements and ensure you are receiving all of the support you are entitled to based on your circumstances.

TheirYour current income support

– please select which types of income currently apply

We use the (optional) information about other organisations involvement to make contact with professionals with whom you are already involved with, to ensure we compliment any existing support you may be receiving and to prevent duplication or repetition.

Are there any other organisations or professionals involved in supporting the individualyou?

We will only ever share relevant information with your consent, or unless we have a legal duty to do so. You can change your preferences whenever you like, and whilst you don’t have to provide your consent at this stage, it may help you access support quicker.

After reviewing your referral we may identify another organisation that is more suitable to provide you with support or advice.

Please confirm whether you are happy for us to contact them on your behalf, and share with them any relevant information.

Are you happy for us to do this?

Colour Scheme: