Description of rough sleeper and their location

• Name (if known)
• Age (approx or DOB if known)
• Ethnicity
• Gender: Male Female Unknown
• Hair (colour, long/short, bald or facial etc.)
• Approximate height
• Other identifying features
• Location/area* Full description of sleeping site (e.g. shop doorway, stairwell of block of flats, under bridge etc.) If you are unsure of the exact location, please visit Google Maps
• Have you seen this person sleeping rough: Yes No
• Length of time at this location? (if known)
• What times are they usually here?

Additional information

• Please give details if they are exhibiting any concerning behavior (eg. Isolation, paranoia, threatening verbal/physical behavior).
• Please give any information that would enable staff to safely contact or approach the individual.
• If you are aware that they are engaging with homeless services, please give details so we can coordinate our work.

• Are they aware of this referral?*

  Yes No Don't know

• Are you aware of any specific support needs?

  Drugs/substance use Alcohol use Personal care Physical disability Elderly Young Chronic illness

Your contact details (optional)

• Your name
• Organisation/Agency (if applicable)
• Your contact number
• Your email address

We may contact you for further information or to update you on the outcome of your referral. We will not retain your details for any other purposes.