Community Hub

Referral form

Homelessness Prevention support delivered at the Booth Centre
Referring in

This form can be completed by a person looking for support or by an agency supporting that person. If you are completing this form on paper, please email it to communityhub@boothcentre.org.uk.
Who can access this support?

This service is for people at risk of homelessness or rough sleeping, who would like support to maintain their accommodation
- You should be over the age of 18
- Couples can be referred, as well as single people
- Offending history is not a barrier to receiving our support
- You should be currently located in Manchester or Greater Manchester
- This service is not for families
What can we offer?
- Employment and Income support
- Help with issues between you and your accommodation provider or landlord
- Support to find a long-term home
- Advice and support if mental health or substance misuse is having a negative affect on how you manage your tenancy or temporary accommodation
- Quality signposting and direct links into specialist support agencies
This service is not for people who are rough sleeping. If you or the person you are supporting is rough sleeping, please contact your local authority's outreach team or find more information about the Booth Centre's full service here

If you are completing this form for yourself, please go to the next page.
Referrer's Information
Referrer's Name

First NameLast Name
Referrer's Email
example@example.com
Referrer's Contact Number
How do you know the person being referred?
If you work for a support agency, please include details of the organisation

How can we help?
Choose the options which best describe the support you are looking for

Help to find employmentAdvice and support around my financesHelp to resolve an issue between me and my private landlordHelp to resolve an issue with my temporary accommodation providerProvide me support with things that are having a negative affect on how I manage my tenancy or temporary accommodationOther
If other, please describe
Tell us what you would like to achieve with the support of the Prevention Hub

Anything else you would like us to know?

This will help us make sure the support you get is right for you
Do you have any health conditions?
e.g. Physical or mental health conditions
Do you consider yourself as having a disability?
If yes, please describe
Do you have a support worker?
If yes, please tell us their name, contact info and where they work
What is your immigration status?
Do you have access to public funds?
Nationality?
Ethnic Origin?

Consent
By confirming your consent below, the information from this referral form will be inputted into our database, Inform. This database is accessible only to the Booth Centre team and has a 2-step verification process security measure. For more information on how we store and use your data, please click on the link below.
Please read our Privacy Statement here
I give consent for information on this referral form to be shared with the Booth Centre team.

Yes
I give consent for my contact details to be shared with Housing Providers

YesNo
Signature of person being referred

Clear
Date of referral

DayMonthYear
Should be Empty:

Referral form