Individual Person - Referral Form
Transitional Housing
Please fill in the form truthfully and accurately, when the form has been submitted it will be automatically sent to our Referral team, who will review the form and contact you if anymore information is needed. You will ONLY be informed if your referral is successful and you will then move on to the next stage of your application [Please Note This Housing Model Is Not Supported Accommodation]
Applicant Details
Where did you hear about us?
*
Date of Form Completion?
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Full Name
*
First Name
Last Name
Email
*
example@example.com
Contact Number
*
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
National Insurance Number
*
Gender
*
Male
Female
Prefer not to say
Other
Nationality
*
Current Address
*
Street Address
Street Address Line 2
City
County
Post Code:
Length of time at current address?
*
Please Select
0-6 months
6-12 months
12 months to 2 years
2 years +
How is the property you reside in held by you?
*
Private Tenant
Lodger
Tenant of Housing Association
Owner
Living with family
Council tenant
Your current landlords Name, Phone number & Contact details
*
Are you in receipt of Universal Credit?
*
Yes
No
Applied, waiting to hear
When did you first start receiving UC?
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
How much do you receive for Universal Credit?
*
How is this benefit paid to you?
*
Weekly
Fortnightly
Monthly
What date is this benefit payment normally paid to you? (e.g. 15th)
*
Do you have a Online Journal to Manage your Universal Credit Claim?
*
Yes
No
Are you in receipt of any other benefits?
*
No
PIP
JSA
Child Benefit
ESA
Child Tax Credits
Other please state
When did you first start receiving this benefit?
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
How much do you receive?
*
When is this normally paid to you?
*
Weekly
Fortnightly
Monthly
What date is this benefit payment normally paid to you? (e.g. 15th)
*
Please state any further details about the additional benefits you receive if needed
*
Are you employed?
*
Yes
No
If YES, how many hours per week?
*
How much do you earn per month before deductions?
*
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Previous Address History
Previous 5 address History
Rows
Address
Date/Duration
Landlord Details
Type of accommodation
Reason for Leaving
Address 1
Private Rented
Owned
Social Housing
Supported Housing
Living with family
Other (Please state below)
Address 2
Private Rented
Owned
Social Housing
Supported Housing
Living with family
Other (Please state below)
Address 3
Private Rented
Owned
Social Housing
Supported Housing
Living with family
Other (Please state below)
Address 4
Private Rented
Owned
Social Housing
Supported Housing
Living with family
Other (Please state below)
Address 5
Private Rented
Owned
Social Housing
Supported Housing
Living with family
Other (Please state below)
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Applicant Medical Background/History
Social worker, CPN or any other Medical professionals
*
GP Name and Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mental Health History
*
Physical Health History
*
Present Medication or Treatment (if applicable)
*
Any other relevant information
*
Please state Probation Officer name & Contact details if applicable
*
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Risk Assessment
Please indicate if you are at risk of any of the below
Have you been involved in any of the following?
*
Rows
Yes
No
If YES please state details
Violence, aggressive behaviour (Verbal and/or Physical)
Self-Harm / Suicide / Mental Health formal diagnosis
Drug/alcohol Missuse
Medication: Non-compliance, memory issues, unintentional/intentional overdoes
Safeguarding Concerns
*
Rows
Yes
No
If YES please state details
Child protection issues
Criminal Convictions
Self-neglect / neglect of others
Antisocial Behaviour
Damage to Property
Neighbourhood Problems
Arson/Firearms
Rent arrears/finances
Are you currently or have you previously been registered on the Sex Offenders register
Other questions/concerns
*
Rows
Yes
No
If YES please state details
Have you ever been evicted?
Are you at risk of exploitation or abuse from others?
Are there any other risks we need to be aware of?
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Next of kin or significant other
Appointee etc.
Name
*
First Name
Last Name
Contact Number
*
Email
*
example@example.com
Relationship to applicant
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Equality, Diversity and Inclusion
Please fill in the table below, if Yes please state in the details box
*
Rows
Yes
No
If Yes -Details
Does the applicant have any cultural, ethnic, religious or other specific needs?
Does the applicant have any physical disability, accessibility or additional needs?
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Authorisation - Applicant
For the applicant of the form to complete.
Please state your preferred location? e.g. Hartlepool, Middlesbrough (if accepted)
*
Please state preferred address (if you have seen an advert for a property on our social media, if not add "No preference")
*
Please state how many adults will form your household and reside at the property. (If applicable)
*
Please state how many Children (under 18) will form your household and reside at the property. (If applicable)
*
Please state If you have children please stated below their ages & Genders & Date of Birth for & if you have a partner please also state this information too
*
Our Transitional Housing Model consists of Self contained & Shared accommodation, please specify below your preference (We will endeavour to accommodate your requirement but it is not guaranteed)
*
Self Contained - Flat 1x Bedroom
Shared Home - 1 Bed Room, Shared Kitchen & lounge
No preference - Self contained Flat or Shared Home
2 Bed Property
3 Bed Property
Please state what is your furniture requirement? (if you are in a shared home please tick not required)
*
Full Furnished - White Goods & Sofa & Beds & Wardrobe & Dining Set
Part Furnished - White Goods but No furniture
Not Furnished - No White Goods or Furniture Provided
Not Required
Name
*
First Name
Last Name
Date of form completion
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
I confirm that I am over 18 years of age and the information given above is true and accurate. I confirm that no one will be living in the property except anyone who is named above.
*
Be aware that after the submission
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