Referral Submission

All sections to be completed by referring organisation.

"*" indicates required fields

Referral Agents Details

Referral Agency Name*

Referred By*

Date of referral*

Reason for referral*

Referrer's Telephone Number*

Referrer's Email Address*

Referred Person's (Applicants) Details

Title*

Forenames*

Surname*

Current Address*

Date moved to current address*

Previous / other name/s*

Prison release date (if applicable)*

Date of birth (DD/MM/YYYY)*

Age (at date of referral)*

National Insurance Number*

Mobile Phone Number*

Email Address*

Nationality*

Immigration status / Date last entered the UK*

What Identity documents are held (e.g. passport, driving licence, birth certificate)*

Does the applicant have a Right to Reside in the UK, and a Right to Rent a property*

Is English your first language?*

Does the applicant communicate in English?*

Pregnancy / Maternity*

Applicants Gender*

Applicants Gender Other*

Next of Kin (full name, and relationship to the applicant)*

Next of Kin contact details (address and phone number)*

Emergency / Alternative Contact Name*

Emergency / Alternative Contact Details*

Vehicle Details (make, model, colour, registration)*

Has Applicant served in the UK armed forces? (if yes, please state regiment and service number)*

Do you have any pets?*

Pet details*

Do you have a bank account?*

Name of the Bank*

Name on the Account*

Sort Code*

Account Number*

Current Accommodation

Current Accommodation*

Current Accommodation Other*

Please provide details of your last three addresses (including current address)

Most Recent Address

Address*

Name and Address of Landlord (and Landlord’s Tel number)*

Dates of Occupation From / To*

Reason for leaving*

Second Most Recent Address

Address*

Name and Address of Landlord (and Landlord’s Tel number)*

Dates of Occupation From / To*

Reason for leaving*

Third Most Recent Address

Address*

Name and Address of Landlord (and Landlord’s Tel number)*

Dates of Occupation From / To*

Reason for leaving*

Housing Benefit

On what date did you last claim Housing Benefit?*

To which Council?*

Assessed Support Needs & Risk

Each question MUST be answered before the form can be submitted

Alcohol Misuse*

Level of risk*

Risk details & agency contact information*

Debt Issues*

Level of risk*

Risk details & agency contact information*

Disability - Learning*

Level of risk*

Risk details & agency contact information*

Disability - Mental Health*

Level of risk*

Risk details & agency contact information*

Disability - Physical*

Level of risk*

Risk details & agency contact information*

Disability - Sensory*

Level of risk*

Risk details & agency contact information*

Domestic Abuse*

Level of risk*

Risk details & agency contact information*

Drug Misuse*

Level of risk*

Risk details & agency contact information*

Homelessness / Previous Evictions*

Details*

Sexual Abuse / Sex Worker*

Level of risk*

Risk details & agency contact information*

Violence*

Level of risk*

Risk details & agency contact information*

Offending*

Level of risk*

Risk details & agency contact information*

Arson Offences*

Details*

Schedule 1 Offences against a person under 18?*

Details*

Self Harming History*

Details*

Intravenous use (e.g. heroin, insulin)*

Details*

Time spent in homeless hostels, domestic violence refuge, or drug/alcohol rehabilitation*

Time spent in Local Authority care as a child: Please specify approximate dates and which local authority*

Support Funding*

Is the referred person entitled to funding to meet their support needs, (e.g. via Adult Social Care or NHS services)?

Details*

Welfare Benefits
Please list social security benefits and other welfare (e.g. tax credits) currently received, the amount received, and the start date of each benefit claimed.

Welfare Benefits 1*

Welfare Benefits 2*

Welfare Benefits 3*

Welfare Benefits 4*

Other Information
Provide any further information and reference any information attached to this referral in this space Specify details of any and all known risks not already stated above, e.g. mental health, addictions, violence, offending, anti-social behaviour, property damage, exclusions/bans from specific areas/locations/people. This is also where you can add further details about how and why the referred person has become homeless or in need of our supported accommodation.

Please provide any extra information*

Declaration by Referring Organisation

(This MUST be completed by the referring organisation before we can accept the referral)

I declare that I am acting on behalf of the referring organisation and I have made an initial risk and support needs assessment of the referred, based on my knowledge of the person, their situation, and the information held by our organisation, I understand that withholding information may put the lives of workers and residents at risk, and I assert that all relevant information has been fully declared and detailed on this form.

I confirm that I have verified the person’s Right to Rent status. I confirm that we are GDPR compliant. I confirm that we can be held liable if Choice Housing Ltd relies upon this referral when relevant information is withheld, omitted, or wrongly stated, by us and as a result Choice Housing Ltd provide accommodation to the person referred and suffer damages (costs) as a result.

I am satisfied that Choice Housing Ltd are able to provide the type and level of support this client requires (including signposting to other support if required). The person referred is aware of and agreeable to this referral, and agrees with the support needs assessment I have made.

Confirmation*

I agree to the declaration.

Declaration by individual who has been referred

(This section can be signed by the referred person during an assessment or property viewing)

I confirm that I wish to apply for supported accommodation with Choice Housing Ltd and that I will engage with the Support Workers weekly and accept all the support offered to me by them. I declare that if I accept an offer of accommodation granted as a result of this application, I will move in and live there within 1 day of signing the occupancy agreement, and I will not allow anyone else to reside in my room or leave my keys with any other person.

I understand that the details given on this form will be held by Choice Housing Limited for the purpose of assessing my application, managing my occupancy, and may also be shared with others for the purpose of making a Housing Benefit claim, referencing, verification of data, recovery of debt, evidence in court, and the prevention or detection of crime as permitted under the EU Data Protection Regulation (GDPR). I grant Choice Housing Limited the right to process my personal data for the purpose of assessing my application, managing any subsequent tenancy/occupancy, making any benefit claims, providing any necessary support and any other matters arising from my tenancy/occupancy including any debts incurred. I understand that Choice Housing Limited will ensure my personal data is held securely under the EU Data Protection Regulation (GDPR) and will review the need to hold my data periodically. I hereby consent to Choice Housing Ltd making such inquiries as it deems necessary for the processing of this application and the management of any occupancy offered. I request that all persons, companies, authorities, or organisations, provide Choice Housing Limited with such information as may be requested by them. I confirm that I provide consent on behalf of any of my children, that Choice Housing Limited can process any of their personal data for the purposes or processing this application and managing my occupancy.

I declare that the details given on this form are full and correct. I understand that providing any false, misleading, or incomplete information or statement may constitute a criminal act of fraud or misrepresentation and will also make any tenancy/licence/contract voidable (and/or able to be rescinded) by the landlord. I declare that the information on this form can be used and relied upon when making a claim for Housing Benefit or other benefits, and I give my permission for the information to be used for this purpose.

I understand that I can apply in writing to Choice Housing Limited to request a copy of my personal data held by Choice Housing Limited. I understand that I can withdraw my consent for Choice Housing Limited to hold my personal data, but that this will affect my application and any subsequent tenancy/occupancy, and once permission is given Choice Housing Limited can hold my data under the regulations and or for legitimate business use until all matters arising from my tenancy/occupancy have ceased. I understand that Choice Housing Limited will not sell my data to any third party and will only share my data for the purposes outlined above.

I understand that all information provided by or about me may be used for the Housing Benefit claim and I declare that the information I have given on this form is correct and complete. I understand the following: If I give information that is incorrect or incomplete, the Council may take action against me. This may include court action. The Council will use the information I have provided to process my claim for Housing Benefit and/or Council Tax Support. The Council may check some of the information with other sources as allowed by the law. The Council may use any information I have provided in connection with this and any other claim for Social Security benefits that I have made or may make, and may give some information to other organisations, such as government departments, local authorities and private-sector companies such as banks and organisations that may lend me money, if the law allows this.

I have read, or have had read to me, and understand the information in this document, and I am aware that I must let the council know in writing, or online, about any change in my circumstances which might affect my claim. I have read, and agree to the declaration, and I confirm that all of the details I have provided are correct.

Signed (Applicant)

Date

Phone

This field is for validation purposes and should be left unchanged.