Name (if known):<BR> <INPUT NAME="Name (if known)" TYPE="text" SIZE=20 MAXLENGTH=30><BR>
<BR>
Age Please indicate approximate one<BR>
16-20: <INPUT NAME="16-20" TYPE="checkbox">
21-30: <INPUT NAME="21-30" TYPE="checkbox">
31-40: <INPUT NAME="31-40" TYPE="checkbox">
41-50: <INPUT NAME="41-50" TYPE="checkbox">
51-60: <INPUT NAME="51-60" TYPE="checkbox">
60+: <INPUT NAME="60+" TYPE="checkbox">
<BR>
<BR>
Ethnicity: <BR><INPUT NAME="Ethnicity" TYPE="text" SIZE=30 MAXLENGTH=30><BR>
<BR>
Gender<BR>
Male: <INPUT NAME="Male" TYPE="checkbox">Female: <INPUT NAME="Female" TYPE="checkbox">
Unknown: <INPUT NAME="Unknown" TYPE="checkbox"><BR>
<BR>
Hair (Long, Short, bald, colour, facial hair, other):<BR> <INPUT NAME="Hair (Long, Short, bald, colour, facial hair, other)" TYPE="text" SIZE=30 MAXLENGTH=30><BR>
<BR>
Approximate height:<BR> <INPUT NAME="Approximate height" TYPE="text" SIZE=30 MAXLENGTH=30><BR>
<BR>
Other Identifying features
<BR><textarea NAME="Other identifying features" ROWS=6 COLS=40></textarea><BR>
<BR>
Location<BR>
Name of street and full description of sleeping site (e.g. shop doorway, under bridge, stairwell of block of flats etc). If you are unsure of the exact location, please provide as much detail as possible.
<BR><textarea ROWS=8 COLS=40></textarea><BR>
<BR>
Length of time at this location (If Known):<BR> <INPUT NAME="Length of time at this location (If Known)" TYPE="text" SIZE=30 MAXLENGTH=30><BR>
<BR>What times are they usually here? :<BR><INPUT NAME="What times are they usually here? " TYPE="text" SIZE=30 MAXLENGTH=30><BR>
<BR>
Are you aware of any risks that this person may cause to themselves or other individuals? (Please indicate your answer)<BR>
Yes: <INPUT NAME="Yes" TYPE="checkbox">
No: <INPUT NAME="No" TYPE="checkbox">Don't know: <INPUT NAME="Don't know" TYPE="checkbox"><BR>
<BR>
If yes, who might they pose a risk to: (please indicate your answer)<BR>Themselves: <INPUT NAME="Themselves" TYPE="checkbox">
Other individuals: <INPUT NAME="Other individuals" TYPE="checkbox"><BR>
<BR>
Please give any information that will be helpful for professional staff to safely contact or approach the individual:<BR>
<textarea ROWS=8 COLS=40></textarea><BR>
<BR> Is the person who is sleeping rough aware you are making this referral? (Please indicate answer)<BR>
Yes: <INPUT NAME="Yes" TYPE="checkbox">
No: <INPUT NAME="No" TYPE="checkbox">
Don't know: <INPUT NAME="Don't know" TYPE="checkbox">
<BR>
<BR>Are you aware of any specific support needs? (Please indicate)<BR>
Drugs/Substance: <INPUT NAME="Drugs/Substance" TYPE="checkbox">
Alcohol: <INPUT NAME="Alcohol" TYPE="checkbox">
Mental Health: <INPUT NAME="Mental Health" TYPE="checkbox">
Health: <INPUT NAME="Health" TYPE="checkbox">
Elderly: <INPUT NAME="Elderly" TYPE="checkbox">
Young: <INPUT NAME="Young" TYPE="checkbox"><BR>
<BR>
Your contact details (optional)<BR>
Name: <BR><INPUT NAME="Name" TYPE="text" MAXLENGTH=60><BR>
Organisation/Agency: <BR><INPUT NAME="Organisation/Agency" TYPE="text" MAXLENGTH=60><BR>
Your contact number: <BR><INPUT NAME="Your contact number" TYPE="text" MAXLENGTH=60><BR>
Your email address:<BR> <INPUT NAME="Your email address" TYPE="text" MAXLENGTH=60><BR>
<BR>
We will only use your details if we require more information from you.<BR> Thank You<BR>
<form action="mailto:XXX.XXX@example.com?subject=Rough Sleeper Alert" method="post" enctype="text/plain">
<table><tr><td>
