New Resident Referral Form

New Resident Referral Form
Name*

First NameLast Name
National Insurance Number*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Date of Birth *
Gender*

MaleFemaleOther
Are you currently pregnant?*

YesNoMaybeNot Applicable
What is your full current address?*
Postcode of your current address?*
select ethnicity*

White BritishWhite IrishWhite OtherAsian British IndianAsian British PakistaniAsian British BangladeshiAsian British OtherArabIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black, Black British, or Caribbean backgroundMixed or multiple ethnic groupsWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or multiple ethnic backgroundEnglish, Welsh, Scottish, Northern Irish or BritishIrishGypsy or Irish TravellerRomaAny other White backgroundOther ethnic group
Place of Birth?*
Sexual Orientation*

HetrosexualHomoSexualStraightGayLesbianPrefer Not to sayOther
Marital Status*

singleType option 2Type option 3Type option 4
Religion*

No Religion/AthiestIslamHinduChristiancatholicBuddhismSikhPrefer Not to sayOther
Communication Needs*

Spare RoomLarge PrintBrailleAudiotape/CDBSL/MakatonTranslation/InterpreterOther
Please provide the full name of your Next of kin.*
What is the full address of your Next of kin?
What is your relationship with your Next of Kin?*

ParentSpouseSiblingSon/DaughterFriendOther
Next of kin's phone number?*
What is your current living situation?*

living with parentsOther
Why do you want to move from your current accommodation?*
What was the last address you claimed Housing Benefit from?*
When did that housing benefit start?*

MonthDayYear
Date
Please tick your preferred areas*

LadywoodEdgabastonStockland GreenKingstandingErdingtonHandsworthBartley GreenHall GreenNorth FieldAcocks GreenYardleyWinson GreenStech FordSpark HillSmall HeathSelly OakPerry BarMoseley
Are you on the Birmingham City Council waiting list for housing? If yes, how long?*
How long have you been living in Birmingham?*
Please state all criminal convictions (if any) including dates and time served.*
Do you have any S1 or Arson offences? (Please provided as much detail as possible)*
If you are on probation, please state the officer's details and when the order ends.
Do you have any alcohol or drug uses (past or present)? If so, please detail how often and which drugs.*
Do you have any mental health issues?*
Do you have any physical health issues?*
Detail all medication being taken (including methadone script).*
Do you have any debts? If so, please provide details.
Do you have any issues with gambling? If so please provide details.
Do you have any other conditions you think you have to make us aware of?*
Do you have contact with any other external support teams?*

YesNo
Are you engaging with support so far and/or are you willing to cooperate further with our support services?

Yes I have no Issues with itI may find this difficult
Please tick all the areas of support that you feel apply to you... Please note this is supported housing and so if you have no support needs, unfortunately, we wont be able to house you.

Tenancy failure or losing short-term accommodationBecoming homeless/evicted (within 28 days)Ongoing issues with drug and alcoholAbility to manage ongoing health problemsAccess to local services Rough SleepingAccess to health servicesImproved quality of lifeBuild an alternative support networkSkills to eat healthilyAccess voluntary servicesAbility to manage personal hygieneRisk of domestic abuseIncrease social and community networksFrequent presentation to accident and emergencyUnplanned hospital admissionsReduce social isolationIncreased feelings of being more independentAbility to manage health & wellbeingAbility to manage finances betterDeveloping interpersonal skillsIncreased knowledgeIncreased confidenceAccessing drug and alcohol servicesObtaining or maintaining a suitable home
Have you ever served in the British Armed Forces? If yes, have you ever been injured/disabled from doing so?
How would you describe your status?*

Receiving BenefitsLooking for WorkUnable to WorkWorking (Over 16 Hours)Working Parttime (Less than 16 Hours)Self EmployedInterested in EducationOther
What benefit do you receive?*

Universal CreditESAPIPState PensionOther
How much are you receiving and how often?
When is your next payment due?

MonthDayYear
Date
What is the name and or location of your benefit office?*
Please note, there is a service charge of £17.50 per week to stay at a Walking Waters Supported Housing, we ask that this be paid 4 weeks in advance. This would mean that we would require £70 on the day you move in.*

I understand and this is OK.I can pay this if I want to take a roomI understand this. but may struggle to pay all in advanceI am not willing to pay service charge to stay
Lastly, We need to be very clear that this is supported housing. You must engage in the support sessions, which will be at least 1hr per week. Please confirm this is the correct service for you.*

I understand and have no issues engaging in weekly support sessionsI really need accommodation but don't want to engage with the supportI don't really like the idea of engaging with the support
Did someone refer you to us? Please enter their name below so we can thank them!
Proof of Benefits Without proof of benefits we will not be able to offer you a placement.Please add your most recent statement here or send it via email/WhatsApp before your viewing.

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Photo ID. Please add a clear picture of your ID here or send it via email/WhatsApp before your viewing

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