Description of rough sleeper

Name (if known):

Age* (approximate DOB if known):

Ethnicity:

Skin colour*:

Gender*:
 Male Female Unknown

Hair* (colour, long/short, bald or facial etc):

Approximate height:

Other identifying features:

Location

Area*:
---AshfordCanterburyDartfordDoverGraveshamMaidstoneSevenoaksShepwaySwaleThanetTonbridge and MallingTunbridge WellsMedway

Town*:

Name of street*:

Full description of sleeping site* (e.g. shop doorway, stairwell of block of flats, under bridge, bin shed etc.) If you are unsure of the exact location, please visit Street Map (opens in new window)

Length of time at this location? (if known):

What times are they usually here?

Additional information

Are you aware of any risks that this individual may pose to themselves or other members of the community?*
 Yes No Unsure

If yes, please provide us with further information that would enable our staff to safely make contact or approach the individual:

Are they aware that you have contacted us?*
 Yes No Don't Know

Are you aware of any specific support needs?*
 No Drugs/substance Alcohol Health Mental Health Elderly Young

Your contact details (optional)

Your Name:

Your organisation/agency (if applicable):

Your Email:

Your contact number:

We will only use your details if we require more information from you about this referral.

Please tell us where you heard about the "Don't Just Walk Past" campaign*

---Radio AdvertPorchlight websitePosterLeafletBusiness CardLocal newspaperTelevisionTwitterFacebookSearch Engine e.g GoogleWord of mouthOther (please state)

Other:

*These details are required