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.)*

  • 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

  • As the person making this referral, how long have you worked with the person being referred?   *   
        *  

  • Is the person being referred aware that you are making this referral on their behalf?*
    • Applicant Details 
    • Has the applicant been known by any other names?*
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    • What are the applicant's preferred pronouns*
    • What identification can the applicant provide?*
    • Is the applicant eligible for Housing Benefit?*

    • Please note that if there is a reason why the applicant currently isn't eligible for Housing Benefit and will not be eligible in the future then we will not be able to consider them for housing with us. 

       

      However, if there is a temporary situation, please explain this in the box above so we can take this into consideration when assessing this application. 

    • Does the applicant have an active bank account IN THEIR OWN NAME?*
    • Does the applicant have a Personal Housing Plan (PHP) with their local authority?*
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    • Support Needs Assessment 
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    • Is the applicant currently involved with other agencies (GP, CPN, psychiatrist, mental health worker, support worker, safeguarding etc)*
    • Risk Assessment 
    • Has the applicant lived in Supported Accommodation before?*
    • Does the applicant have any outstanding debts/rent arrears?*
    • Has the applicant ever been evicted from a property before?*
    • Can the applicant provide another reference (beyond the original referrer)? For example, a previous landlord, support worker, medical professional etc.?*
    • Is the applicant on any medication?*
    • Is there any risk of self harm or suicidal thoughts?*
    • Has the applicant had any previous incidences of damaging property?*
    • Has the applicant had any previous incidences of threatening, intimidating or injuring staff?*
    • Has the applicant had any previous incidences of threatening, intimidating or injuring other service users?*
    • Has the applicant ever been convicted of a criminal offence?*
    • Is the applicant currently under investigation of a criminal offence? Or does the applicant have any pending court cases*
    • 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
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