Transitional Housing Referral Form

Applicant details
Applicant name*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact number*
Please enter a valid phone number.
Date of birth*

DayMonthYear
Date
NI number*
Gender
Nationality*
Reason for referral*
(Brief reason for referral and background details for applicant)
Preferred Location
Has the applicant agreed to this referral?

YESNO

How many children are in your household?*
Are you in hospital/residential care, a prisoner, on strike, living abroad or a full time student? *
Are you employed?*
If YES, how many hours per week?
How much money do you earn per month before deductions
Do you receive disability or sickness benefit?*
Common disability benefits are Attendance allowance, Disability Living Allowance (DLA), Personal Independence Payment (PIP), Employment and Support Allowance (ESA), Universal Credit limited capability for work element (LCW/RA) and Statutory Sick Pay (SSP)
Are you ill or disabled but not claiming one of the disability benefits listed above? *
Do you care for someone who is sick or disabled?*

Last 5 addresses

Please answer all of the below*

	Yes	No	Details
Does the applicant have any cultural, ethnic, religious or other specific needs?
Does the applicant have any physical disability, accessibility or additional needs?

Authorisation - Applicant

For the applicant of the form to complete.
Has the applicant agreed to this referal?
- I give my consent to the disclosure of this information for the purpose of finding accommodation and to the disclosure of any supplementary information attached for housing purposes, in line with GDPR regulations.
- I give my permission for the outcome of this referral to be explained to the referral agency if required.
- I agree to participate in coaching services which are included as part of my tenancy agreement.
I consent to the above terms

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Date

DayMonthYear
Be aware that after submission, you will have the option to download a copy of your referral document.
Should be Empty:

	Yes	No	Details
Violence, aggressive behaviour (Verbal and/or Physical)
Self-harm / suicide / mental health formal diagnosis
Drug/Alcohol Misuse
Medication: Non-compliance, memory issues, unintentional/intentional overdose.

	Yes	No	Details
Child protection issues
Sexual or schedule 1 offence
Criminal convictions / offences
Self-neglect / neglect of others
Antisocial Behaviour
Damage to property
Neighbourhood Problems
Arson/Firearms
Rent arrears/finances

	Yes	No	Details
Has the tenant ever been evicted?
Risk of exploitation or abuse from others
Any other risks
Is the applicant at risk of harm from others?Please provide details if yes.
Should any precautions be taken into account when interviewing the candidate?

Applicant details