Housing Advice Common Referral Form V by 3u8736Qa

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									      Housing Advice Common Referral
                 Form V.2
      REFERRAL AGENCY / PROFESSIONAL DETAILS
                                                                                                                         All contact
        Date form filled in                                                                                             details for
                                                                                                                         member of staff
     Full name of referrer                                                                                               or professional
                                                                                                                         agency filling in
          Agency / Office                                                                                                form.

         Contact Number

                      Email
                               *If the applicant already has a support worker, they must go to the support worker
         Support Worker*       and ask for a referral to Housing Advice                                                  Tick if you know
                                                                                             CYPS (under                 which team you
      Single or Couple               Families            Tenancy Relations                                           
                                                                                                18)                      are referring to.


                         DETAILS OF MAIN APPLICANT
                                                                                                                         Enter primary
  Name                                                                             Northgate Ref                        applicant details
                                                                                                                         here. Please
Aliases                                                                                       NINO                       also include
                                                                                                                         details of any
                                                       *If the applicant is under 18, please list all siblings and
      Age*                    DoB                                                                                        family members,
                                                       parents in the boxes below
                                                                                                                         partners or
      Male         Female           Pregnant             If pregnant, give estimated due date                            dependent
                                                                                                                         children also
                                                                                                                         applying.
             Phone
Contact
             Mobile
 info
              Email
                                                                                                                         We can provide
     Interpreter required?          Yes          No             Language                                                an interpreter if
                                                                                                                         required.
       Ethnicity

             Names of other adults & children in the household                      DoB             Relationship
                                                                                                                         All other
1.                                                                                                                      household
                                                                                                                         members should
2.                                                                                                                       be entered here.
                                                                                                                         If there isn’t
3.                                                                                                                       enough space,
                                                                                                                         please supply
4.                                                                                                                       other members
                                                                                                                         on a separate
                                                                                                                         sheet.
5.
                                                                                                                         Children are
6.                                                                                                                      deemed
                                                                                                                         ‘dependents’ if
7.                                                                                                                       they are
                                                                                                                         normally
8.                                                                                                                       resident with the
                                                                                                                         applicant, under
9.                                                                                                                       16, or under 18
                                                                                                                         and in full-time
                                                                                                                         education.
10.

                         Please continue family members on another sheet if necessary
      CURRENT AND PREVIOUS ADDRESS HISTORY
                                                                                                          Here we would
Most recent                                                                                              like to build up a
 address –                                                                                                picture of the
please do not                                                                                             accommodation
   use sofa                                                                                               history of the
    surfing                                                                                               main applicant.

Type of accommodation
                                                                                                          Please tick
      With friends / relatives                In prison              Owner-occupier                      which best
                                                                                                          describes their
      Living with parents                     Council Tenancy        Housing Association tenancy          most recent
                                                                                                          accommodation.
      Privately renting                       Hospital               Homelessness Hostel or B&B           ‘Sofa surfing’ is
                                                                                                          not enough
      Rehab / treatment centre                Sleeping out           Private Hotel or B&B                 information for
                                                                                                          us to determine
      Caravan / car / trailer                 Other (details)                                             homelessness.


                  What date do they / did they become homeless?
                                                                                                          Eviction,
                                                                                                         harrassment
 Why do they / did                                                                                        from Landlord,
                                                                                                          fleeing domestic
they have to leave
                                                                                                          violence etc.
    the current                                                                                           Please include
 accommodation?                                                                                           copies of notices
                                                                                                          or eviction
                                                                                                          letters.
Have they been given a ‘Notice to quit’?          Yes           No        Date it ends
                                                                                                          Please provide
 Please give contact details of who is making them homeless, landlord, parent, friend, relative etc      contact details of
                                                                                                          the person or
 Name                                                                     Phone                           housing provider
                                                                                                          making them
  Type of contact – who is this?                                                                          homeless.

                                Address history                             Dates at this address

  Please give last 5 years – continue on separate sheet if necessary         From            To
                                                                                                          For family cases
1.                                                                                                       we will need a 5
                                                                                                          year history
2.
                                                                                                          Singles may be
3.                                                                                                       a bit more
                                                                                                          difficult to obtain,
4.                                                                                                        but please
                                                                                                          supply as much
5.                                                                                                        as you can.
                                                                                                          If actual dates
6.                                                                                                       are not known,
                                                                                                          you can enter
7.                                                                                                        the month and
                                                                                                          year.
8.

9.

10.
                                                                                                          What sort of
  Please only complete the following if the referral is for a FAMILY or someone WITH CHILDREN            accommodation
                                                                                                          does the
 Type of accommodation required                                                                           assessor feel
                                                                                                          they would be
         Preferred areas of Bristol                                                                       best suited to?
                                      ELIGIBILITY
 Please fill this section in to the best of your knowledge. Please do not make assumptions on any of
 the questions. Any UK status information can be gained from the Passport or Travel Document. If
   you cannot determine the answers, leave blank or ring the Housing Advice Team for assistance.
                                                                                                              If possible,
 Nationality                                                                                                 please provide
                                                                                                              photocopies of
                    UK / Irish national                        Indefinite leave to remain                     passports or any
                                                                                                              documentation
                    A8 national                                Limited leave to remain                        that confirms
Status in the                                                                                                 their current UK
     UK                                                                                                       status.
                    A2 national                                Other protection leave to remain

                    Other EEA                                  Other non EEA national

 Proof of eligibility provided / Which document produced?
                                                                                                              How long have
                    Has employment in Bristol             Resident for at least 6 out of last 12 months      they lived in
  Local                                                                                                       Bristol? Do they
                    No connection with Bristol            Resident for at least 3 out of last 5 years         have a job or
Connection
                                                                                                              relatives here?
                    Other reason                          Has immediate family connections

  Have applicant or partner ever been in armed forces         Yes               No


                                   HEALTH ISSUES
                                                                                                              Please provide
                                                                                                             as much detail
                                                                                                              as possible
    Physical                                                                                                  regarding
    health &                                                                                                  diagnosis,
    mobility                                                                                                  treatment,
                                                                                                              support
                                                                                                              mechanisms
                                                                                                              and how day-to-
                                                                                                             day life is
                                                                                                              affected.

      Mental
      Health



                                                                                                              Please also
                                                                                                             provide copies
                                                                                                              of any doctors’
          All                                                                                                 letters or
                                                                                                              prescriptions if
  medication
                                                                                                              available.



                                                                                                              Please indicate
                                                                                                             if currently using
                                                                                                              or on a
     Drug &                                                                                                   substitute, and
     alcohol                                                                                                  also for how
     history                                                                                                  long



                                                                                                              Anything not
                                                                                                             mentioned
   Details of                                                                                                 above. Eg;
          any                                                                                                 Deaf, blind….
  disabilities
                                    OTHER HISTORY
   Have they ever been in care or accommodated by Social Services?               Yes             No             Please indicate
                                                                                                                if they have
Care history                                                                                                   been in care on
                                                                                                                                  th
 (including                                                                                                     or after their 16
post 16 care)                                                                                                   Birthday.

                                                                                                                If they are
   Rough                                                                                                       sleeping rough,
  sleeping                                                                                                      or have done in
   history                                                                                                      the past, enter
                                                                                                                dates and
   Benefits,                                                                                                    places
  income &                                                                                                      Establish
   savings                                                                                                     amounts, either
                                                                                                                weekly or
                                                                                                               monthly and
 Arrears &
                                                                                                                who money is
   debts
                                                                                                                owed to.

Please give contact details of any other agencies or support providers they are involved with (eg; Social
Services, Teacher/Tutor, Outreach, YOT, Probation, Resettlement, Next Link, Women’s Aid…)

Organisation                                                                   Phone                            Any other
                                                                                                                agencies the
       Name                                                                   Mobile                           applicant may
                                                                                                                be known to
                                                                                                                and/or working
        Email                                                                                                   with or relations
                                                                                                                who offer
Organisation                                                                   Phone                           support.

       Name                                                                   Mobile
                                                                                                                If this person is
        Email                                                                                                   currently bailed
 Probation                                                                                                      to an address
                                                                                                               somewhere, we
order or bail
                                                                                                                cannot
 condition                                                                                                      immediately
   details                                                                                                      assist them as
 Prison Number                                                     Release date, if known                       they are not
                                                                                                                considered as
 Any other                                                                                                      homeless. The
  notes or                                                                                                      bail conditions
 assistance                                                                                                     will need to be
  required                                                                                                      changed.

        CONSENT TO SHARE & REQUEST FURTHER CLIENT INFORMATION
                                         Please read this statement to the applicant
It is helpful to us for you to allow your information to be shared by a variety of approved agencies that may be involved in
   helping you with your housing or support issues. It can save you from having to give the same information again and
                             again, and will speed things up at a time when you need help quickly.

   Unless you request otherwise, this form will be shared with other agencies for the purpose of assisting you with your
   accommodation and support needs. You may request this information under the Data Protection Act at any time by
                                               writing to Bristol City Council.
                        Please tick the box if applicant agrees to this statement.
                             Please attach any risk assessments or other information

                                     Once this form has been completed
                               You can email to: housing.advice@bristol.gov.uk
                                         Or fax to: 0117 352 6810

             If you have any queries regarding Housing Advice, please ring 0117 352 6800

								
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