To download the Referral Form, please click here

Agency Details

* Referring Staff Name:
* Referring Agency:
* Agency Address:
* Agency Contact Number:
* Agency Email Address:
* How do you know the client?
* Length of time the applicant has been known to you:

Client Details

* Clients Name:
* Clients Date of Birth:
* Clients Phone Number:
* Clients Medical Card No.:
* Client PPS No.:
* Clients Current Address:
* Reasons for leaving current address?

* Has your client ever been evicted from any accommodation? If yes, please state all reasons

* List all addresses and periods of residence for the last 5 years and reason for move on’s as per example

If your client has moved frequently in the past 5 years, can you provide any underlying reasons why?

Address 1
Periods of residence
Reason for move on
Address 2
Periods of residence
Reason for move on
Address 3
Periods of residence
Reason for move on
Address 4
Periods of residence
Reason for move on
* Is your client registered as Homeless with DCC?
If NO, specify which Local Authority.
Date of Registration at Local Authority:
Local Authority Registration Number:
* Appropriate contact person at Local Authority:
* Please confirm that your client is currently eligible for rent allowance and a deposit?
YesNo

* Please confirm that your client is currently eligible for HAP? allowance and a deposit?
YesNo

Is your client in receipt of a social welfare payment? If yes, please specify which entitlements:
YesNo

* What else is your client eligible for?

* Has your client ever been a victim of ANY type of violence? If yes, please specify:
YesNo

What age was she:

Who was the perpetrator? Known or Unknown to her?:

Brief over view of what happened: i.e. physical violence/sexual violence/behavioural: please note this information is only to ensure that Daisyhouse can ensure the most appropriate support and care plan. i.e. ensure they are matched with the appropriate qualified professionals.

Medically diagnosed health needs and history of client: (Inclusive of all allergies)

Medically diagnosed
Treatment
Services involved?
Medically diagnosed
Treatment
Services involved?
Medically diagnosed
Treatment
Services involved?
Medically diagnosed
Treatment
Services involved?
Medically diagnosed mental health needs and history of client:

Medically diagnosed
Treatment
Services involved?
Medically diagnosed
Treatment
Services involved?
Medically diagnosed
Treatment
Services involved?
Medically diagnosed
Treatment
Services involved?
History of substance, alcohol or other misuse:

Name of drug or alcohol
Treatment
Services involved?
Name of drug or alcohol
Treatment
Services involved?
MName of drug or alcohol
Treatment
Services involved?
MName of drug or alcohol
Treatment
Services involved?



* Name of General Practitioner:
* General Practitioner Address:
* General Practitioner Telephone Number:
Counsellor / Psychotherapist working with your client:
Psychiatrist/Consultants working with this service users:
* Does your client have any history of violence or harm to themselves or others? If yes, please give details:
YesNo

To themselves
What
When
Number of times
Outcome
Current Situation
To others
What
When
Number of times
Outcome
Current Situation
Please provide additional information if any of the following apply to your client:

Been charged with a criminal offence.
Been arrested. What for?
when
Number of times
Outcome
Current situation?
Have any pending court cases.
YesNo

If yes. What for?:

Been in contact with the Gardaí recently over any form of criminal charges. What for?
YesNo

Clients Need and Wants

What are the main three things you need from your time at Daisyhouse.

What are the main three things you want from your time at Daisyhouse.

Employment & Education

If employed currently, or in the past, please give overview; type of work, length of employment etc:

If in training or education at present, please give details:

Please outline any education, training or employment goals your client may have and would like additional support to achieve:

Clients Family

Do you have any children? If yes, please outline their names, ages and care arrangements

How do you describe your client’s situation? Tick as many as required.
Physical disability/illnessHistory of drug/solvent abuse/misuseLearning difficultiesMental health related problemsRelationship breakdown/violenceFinancial DifficultiesTraffickingA history of alcohol abuse/misuseJust out of careOut of prisonOther: if already listed in form, state ‘see above’. If not, please feel in here:

Current level of support/contact from other Agencies:

Name of Agency Staff member:
Agency Name:
Detail level & frequency of support:
Contact number(s) Including out-of-hours/emergency
Will this continue after move into Daisyhouse:

Data Protection Policy

Daisyhouse Housing Association fully respects your right to privacy, and will not collect any personal information without your consent. Any personal information provided will be treated with the highest standards of security and confidentiality, strictly in accordance with applicable data protection and other legislation. While the information provided will generally be treated as private within Daisyhouse and used only for the purpose of the services provided by Daisyhouse, it may be necessary from time to time for us to transfer your personal data on a confidential basis to other bodies to assist with your support needs and move on to long term accommodation (including, but not limited to, the Dublin Regional Homeless Executive, Dublin Co. Council, the County Council related to your own case needs, the Department of Social Protection, An Garda Síochána, the Health Service Executive, Tusla (CFA), social workers, medical practitioners or professional staff related to your care and welfare. We rely on you to provide us with accurate and complete information and to update us in relation to any change in the information provided.