Your Details:

    Date of birth (required):

    Emergency contact details:

    Referral Agency Details

    Please complete this section if you are referring someone to or have been referred to CheckIn/Giraffe by another agency or support person.

    Background details

    Reasons for referral (required)

    Current employment/education status (required)

    Support needs (required)

    Do you/the individual have a condition/disability which is covered by the Equalities Act? (required)


    Do you/the individual have any mental health and well-being needs or challenges? (required)


    Are you/the individual currently being supported by any other agencies? (required)


    Do you/the individual require one-to-one support? (required)


    Do you/the individual have any issues with addiction? (required)


    Offending history

    Do you/the individual have any history of offending? (required)


    If yes, please give the following details:

    Date of last conviction:

    Is there a risk of the individual re-offending? (required)

    YesNoNot applicable

    If yes, please rate level of risk: (required)

    LowMediumHighNot applicable


    The information which has been provided in this form is complete and accurate to the best of my knowledge. Please note that all information provided on this form will be collected and stored under the Data Protection Act 1998.

    (If the form does not submit right away, please check that you have filled in all required fields.)