Clone of Hope Housing Self Referral Form

Hope Housing Self Referral Form

Complete this self referral form to request an assessment.
Applicant details
Full name

First NameMiddle NameLast Name
Other names known by
Gender
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Ethnicity
Address
*If currently homeless, please put none.
National Insurance number
Forms of ID
Contact number
Please enter a valid phone number.Format: 00000000000.
Email address
example@example.com
If no contact number, how can we contact you?
Next of kin
Next of kin name

First NameMiddle NameLast Name
Relationship to you
Next of kin address
Next of kin telephone number
Please enter a valid phone number.Format: 00000000000.
Legal status
Legal status details
Are you a UK resident?
If not a UK resident, do you have pre-settled or full settled status?
Pre-settled or full settled status details
Are you seeking asylum?
Asylum details, including dates and legal representation
Previous address history
Dates from

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dates to

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Accommodation / project address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Accommodation type
Reasons for leaving
Debt / arrears
Financial situation
Do you have access to public funds?
Current source(s) of income
Are you eligible for Housing Benefit?
Amount and frequency of payments
Any deductions from benefits
Hobbies and Interests
What are your hobbies and interests?
Health and support
Physical health conditions / allergies
Mental health issues
Current medication
GP surgery name, address and phone number
Other health workers
Substance use history
Drug and alcohol used now or in the past
Length of time used
How much / how often used
Support agency, worker name and telephone number
Other details to be considered in the application
Equalities and additional needs
Do you consider yourself to have a disability?
Can you read, write and communicate in English?
Religious belief
Offending history
Criminal convictions
Probation worker name and contact details
Pending police matters or court cases
Support needs
Welfare benefits and budget management
Acquiring furniture
Debt management
Employment and job seeking
Volunteer work
Physical health support
Mental health support
Substance abuse support
Access to social or leisure activities
Eating patterns and food preparation
English language learning
Re-establishing contact with family and friends
Other support requirements
Support from other agencies
Name

First NameMiddle NameLast Name
Organisation
Contact details
Details of support
Applicant consent
Applicant name

First NameMiddle NameLast Name
Applicant signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Hope Housing Self Referral Form

Applicant details

Next of kin

Legal status

Previous address history

Financial situation

Hobbies and Interests

Health and support

Substance use history

Equalities and additional needs

Offending history

Support needs

Support from other agencies

Applicant consent

Declaration Of Consent