Refer someone to Good Soil housing

First name

Last name

Email

Your phone number

Organisation / relationship to person being referred

Will you continue to work with this person if they are housed by Good Soil?

Yes

No

About the person you are referring...

First name

Last name

Address / Sofa-surfing / NFA

Date of Birth

Substance use history

Currently using

Past user

No history of substance use

What do/did they use (if none, put N/A, otherwise please tell us what they use, how much and date of last use)

Alcohol use history

Currently using

Past user

No history of alcohol use

What do/did they drink (if none, put N/A, otherwise please tell us what they drink, how much and date of last use)

How would they describe their physical health?

Good

OK

Poor

How would they describe their mental health?

Good

OK

Poor

Please give more details about their physical and mental health including any medications prescribed. (If none, just put 'none')

Do they have a record of offending?

Yes

No

If you answered 'yes' to the question above, please give details of all offences.

Why do they want to apply to Good Soil housing? (in their own words)

Who is in their support network? for example, Cranstoun, social worker, probation officer, friends, family etc.

How did you hear about Good Soil?