REFERRAL FORM : New clients

New Client Referral Form

Elevating Lives Supported Housing
Clients Name*

First NameLast Name
National Insurance Number :
Date of Birth (Must be 21+)*

DayMonthYear
Clients Gender

MALEFEMALETRANSGENDERGENDER FLUIDOTHER
Clients Contact Number:*

Area CodePhone Number
Clients current Address if applicable:

Street Address

Street Address Line 2

CITY

POSTCODE
Does the individual have a local connection to Croydon/Lambeth or are you moving for safeguarding reasons? *
Please state what Borough the referral is for (Croydon or Lambeth) *
In case of emergency
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
What is the individuals current housing status?*

STREET HOMELESS/ HOMELESS SHELTERFLEEING ABUSE/DVPRISON LEAVERHOMELESS - OTHER
(To qualify for supported accommodation the individual being referred must have sufficient need for support) Does the individual being referred have any support needs, other then homelessness?*

YesNo
Please put in DETAIL the individuals support needs -please do not include homelessness in this section *
eg. , mental health issues, substance misuse, offending behaviour, fleeing domestic abuse.
Please explain why the individual would be unsuitable for housing through PRS - Private rented sector*
Please list any other external agencies/ organisations or services that the individual may be engaging with:
EG. Turning point, social services, probation, SLAM etc..
Is the individual being referred currently taking any medication?*

YesNoUnsure
Is the individual being referred currently in employment ?*

Nopart timefull timeself employed
Is the individual being referred currently on benefits ?*

NoUniversal CreditPIPUC limited capacityESAOther
The Accommodation on offer has shared communal facilities, would this be suitable for your client ?*

NoYes
Does the individual require any special requirements/ adaptions with regards to the accommodation?*

NoYes
Has the individual claimed Housing benefit before ?*

NoYes
Does the individual have the following?*

proof of I.Dproof of N.I3 months bank statementsproof of benefitsThe right to public funds
Please attach any relevant/ supporting documents here :

EG. Supporting letter, Proof of diagnosis, Support plans etc.
Cancelof
Referral agents Email*
example@example.com
Referral agency*
Referral agents phone number *
If the Referral is accepted, When will your client be available for a face to face assessment and viewing ? :*
Signature
Should be Empty:

New Client Referral Form