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Referral Form
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Referral Form
Method of Referral
Organisation
Self-referral
Friends or Family
Other
Tenant Information
Full Name
Date of Birth
Current Address
Contact Number
Email Address
National Insurance (NI) Number
Ethnicity
Current Status in the UK
Are you in Receipt of any Benefits?
Yes
No
State which benefits you receive?
Do you have any dependents?
Yes
No
Are the dependents living with you?
Yes
No
Housing Needs
Reason for Referral:
Homelessness
Threat of Homelessness
Domestic Violence
Financial Difficulties
Other
write your specify reason of referral
Current Housing Situation
Staying with Friends/Family
Temporary Accommodation
Private Rental
Other
Write your specify Current Housing Situation
Desired Location(s)
Support Needs
Yes
No
Please provide details
Current Support Services
Social Services
Mental Health Services
Substance Misuse Services
Other
Please specify Current Support Service
Are there any known vulnerabilities or specific requirements?
I confirm that the information provided is accurate and that the tenant has given consent for this referral.
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