Referrer name (if applicable):
Only required if someone else is making the referral on behalf of the applicant.
Referrer email Referrer contact number: Referring agency name: Date of birth: * Applicants email address: Applicants National Insurance number: Nationality: Date entered UK (if not from birth): Entitled to claim benefits in the UK: * Next of kin details: Applicant current address: Date from: Name and contact details of landlord (if applicable): Form of income (Universal Credit, paid work etc.): * Frequency of payment (weekly, monthly etc.) Housing history: *
Please give details covering the last 5 years including dates moved in and out, reasons for leaving etc.
Reason for homelessness: * Current support:
Do you receive support from any of the above?
Current support (further information):
Please give further details of who supports you.
Support needs: *
In which areas is support required.
Applicant’s priority needs:
Please provide details of all of these issues, including current support or medication and how these issues may affect living skills
Education and training:
Please give details of any education, work placements, training or voluntary work
Please provide details of any convictions
Is this person on bail (including police bail): *
Please include if they have ongoing or any outstanding court appearances
Details including bail conditions: Additional information: *
Please use this space to tell us about anything which may help in this application for accommodation.
Does the applicant have a history/is there a risk of any of the following violent offences/incidents to others: * Please give further details of any violent offences/incidents: Is there a history of difficulties regarding previous tenancies: * Please give further details of any tenancy issues: Is there a history of or risk from others/client’s vulnerability of any of the following: * If you are a referral agency, please state how long you have known the Applicant: Equal opportunities - Ethnicity
We aim to promote equality and inclusion to ensure fair access to the service in line with the Equalities Act 2010. These questions are used to monitor access to the service and are not used to make decisions on eligibility or allocation. We will not discriminate unlawfully and our Equality Protocol is available on request.
Equal opportunities - Religion/belief Equal opportunities - Marital/civil partnership status Authorisation *
By submitting this form you agree with the following statements -
I confirm that the information contained in this document is true and includes all relevant information required to correctly assess this referral.
Referral agencies only - I confirm that I have the applicant’s authorisation to submit this application on their behalf and that the information contained in this document is true and includes all relevant information required to correctly assess this referral.
If you agree with DASH processing and storing your details, please tick the above box and click submit.