Single Applicant Referral Form

Single Applicant Referral Form

It is important that this form is filled out as thoroughly as possible by the person completing the referral.
Please use this form to complete your referral on behalf of the person you are referring. At any point, you can scroll to the bottom of the page and click Save which will email you a link to return to the form later.

Once you have completed the referral form, click Submit. This will send the form through to our team who will assess the referral and get back in touch with you as soon as possible.

If you find any issues with this form, please get in touch with us: referrals@renehousecic.com / 0115 901 7866 (option 1)
Please note that we do not accept self-referrals. Is this form being completed by someone in a professional capacity on behalf of the person being referred (eg. support worker, housing options worker, job center work coach etc.)*

YesNo
Unfortunately we cannot accept self-referrals. So, if you are looking to be considered for housing with us, someone in a professional capacity can make a referral on your behalf.

For example:
- Local authority (Housing options worker or support worker etc.)
- Housing organisation (Housing worker or support worker etc.)
- Job center (Work coach)
- GP
- Probation (Probation officer)
- Mental health services (Support worker)
- Substances services (Support worker)
This is not a full list, but the person making the referral must be referring you in a professional capacity (eg. not family or friends).

If you need further information get in touch with us: referrals@renehousecic.com / 0115 901 7866 (option 1)
Details of professional completing this referral form
Name of referring organisation*
Address of referring organisation*
Name of person completing the referral*
Position in organisation*
Phone number*
Email address*
As the person making this referral, how long have you worked with the person being referred? Number*
*
Is the person being referred aware that you are making this referral on their behalf?*

YesNo
Could you give some context as to why not?*
If we need further information on this referral, beyond coming back to you, could you recommend any other professionals who may be able to support this application?

Support Needs Assessment

As the referrer, how much support do you believe the applicant requires in the following areas?*

	Low support	Medium support	High support	No support
Motivation & taking responsibility
Self-care & living skills
Managing money & administration
Social networks and relationships
Drug use
Alcohol use
Emotional & mental health
Physical health
Managing occupancy & accommodation
Work, education and hobbies (meaningful use of time)
Offending
Learning difficulties
History of rough sleeping
Risk of domestic violence

If you would like to add context to any of the answers given above please use this box.
If there are any other areas where you believe the applicant would benefit from more support, please use this box to explain
Is the applicant currently involved with other agencies (GP, CPN, psychiatrist, mental health worker, support worker, safeguarding etc)*

NoYes
Details of other agency involvement
Please make a note of which agencies (if any) will continue to be involved if the applicant is offered accommodation with Rene House

Print, Save or Submit
Please use this box to provide extra detail which couldn’t be put elsewhere or which is necessary to the application. For example:
- Elaborate on current living situation
- Add more context to the Support Needs section above
- Add more context to any information identified in the Risk Assessment section
- Any further information you feel may support the application
Current living situation and support needs*

0/5000
Applicant's next-of-kin
Should be Empty:

Single Applicant Referral Form

Details of professional completing this referral form