St. Martins Housing Homeless Charity

Description of rough sleeper and their location

Name (if known)

Age (approx)

Ethnicity

Gender

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.)

Have you seen this person sleeping rough:

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?*

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.