Accommodation and Housing Support referral form

Title

First Name

Last Name

Date Of Birth

Age

National Insurance Number

Address Line 1

Address Line 2

City/Town

County

Postcode

Phone number

Mobile number

Email Address

Next of Kin

Next of Kin Contact Number

Gender

Ethnicity

Religious Beliefs

Disability

Sexual Orientation

Marital Status

First Language Spoken

Pregnancy & Maternity Status

Referrer Name

Agency/Organisation

Referrer Job Title

Relationship to Referrer

Referrer Address

Referrer Phone number

Referrer Email Address

Which forms of idea do you possess?
Driving licencePassportBirth CertificateHome Office letter stating indefinite leave to remainOther
Please note proof of ID will need to be provided at the Panel Assessment

Have you ever been evicted?
YesNo

Please give details

Are you aware of any arrears for rent or housing benefit?
YesNo

Please give details

Does another person manage your finances?
YesNo

Please give details
AppointeeHave power of AttorneyVoluntarily manage your money

Housing history

Please provide a complete history of your / the applicant’s housing history covering the last 5 years. Please include temporary housing, hospital admissions, prison sentences, homelessness etc. For ‘Type of accommodation’ please specify (private rental, B&B, staying with friends, living with family, hostel, hospital, prison, local authority, housing association etc.)

Date From

Date To

Type of Accomodation

Address

Reason For Leaving

Date From

Date To

Type of Accomodation

Address

Reason For Leaving

Date From

Date To

Type of Accomodation

Address

Reason For Leaving

Date From

Date To

Type of Accomodation

Address

Reason For Leaving

Name of Responsible Officer

Responsible Officer Email Address

Telephone Number

Is the applicant in Custody?
YesNo

Name of prison

Release Date

Offence Details

Community OrderSuspended SentenceLicence

Sentence Expiry Date

Any Local Area Exclusion Zones
YesNo

Please give details

Please provide details of the applicants history and pattern of offending (e.g. summary of previous convictions, repeat victimisation/targeting, triggers or disinhibitors to offending etc).

OGRS 2 Year Reconviction Score

Risk of Harm Assessment
LowMediumHighVery High

Who is at risk of harm?

What is the nature of the risk?

When is the risk likely to be greatest?

What factors are likely to reduce the risk?

Is the applicant subject to MAPPA Level 2 or above
YesNo

Date of next MAPPA Meeting?

Please provide any other information of relevance relating to the risk of reoffending and risk of harm posed

Please give details of any other agencies involved in the management and support of the applicant

Children’s Services / Adult Social Care

Name of Support Worker name