Referral Form - Clifton Housing Project

Online Referral Form

Thank you for completing the online application form. We will respond to you shortly.

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IMPORTANT - PLEASE READ

Prior to completing the application form attached, please read these notes to find out what the service user can expect from Clifton Housing, but more importantly, what the service user will be committing to.

ALL SECTIONS OF THIS FORM MUST BE COMPLETED IN FULL BEFORE A REFERRAL CAN BE CONSIDERED.
All referrals must be made by through a professional body e.g. Mental Health Team, Doctor, Social Worker, CPN, Homeless Services etc.
Clifton Housing provides supported accommodation for those between 18 and 65 years of age, that are homeless or in need of such housing.
Service Users must be willing to follow an action plan, in the hope of leading towards a future of Independent living for each applicant.
Service Users must be aware and understanding of other residents if they are to remain with Clifton Housing.

If you need further information or help in completing this application please call Clifton Housing on (0121) 250 5207.

Details of Person Completing the Form

*Surname

*First Name

*Organisation

*Organisation Address

Post Code

*Email

*Telephone Number

Mobile Phone Number

Section 1: Applicant Details

*Surname

*First Names

Last Contact Address

Post Code

Did you claim your benefits at this address?

Yes

Date of Birth

Age

National Insurance No

Status

Married

Partner

Single

Divorced

Other

Number of Children

Are you a British citizen?

Yes

What is your nationality?

Mobile Phone Number

Section 2: Emergency Contacts

Please complete this section listing your next of kin and details for any organisations That you are presently supported by (e.g. Social Worker, CPN, Mental health teams, Home Treatment Housing Advisor etc.)

Next of Kin

Name

Relationship

Address

Postcode

Telephone No

Support Team A

Name

Relationship

Address

Postcode

Telephone No

Support Team B

Name

Relationship

Address

Postcode

Telephone No

Section 3: Benefits Status

Are you getting any Benefits or Allowances or waiting to hear about Benefits or Allowances you have claimed for?

Yes

Please complete the following to show which benefits you are currently receiving or have applied for. Please ensure dates and amounts are completed.

Benefit One Outer Panel

Name of Benefit

Are you:

Getting it Now

Waiting to Hear

Benefit One Inner Panel

Date First Paid

How Much

How Often

How is it Paid

Bank

Cheque

Cash

Benefit 2 Outer Panel

Name of Benefit

Are you:

Getting it Now

Waiting to Hear

Benefit 2 Outer Panel

Date First Paid

How Much

How Often

How is it Paid

Bank

Cheque

Cash

Section 4: Health and Medicine

Are you registered with a doctor?

Yes

If “Yes” please give details

Are you on any medication at present?

Yes

If “Yes” please give details

Are you on a mental health section?

Yes

If “Yes” please give details

Do you have any allergies or medical conditions we should be aware of?

Yes

If “Yes” please give details

Section 5: Drug and Alcohol Use

Please complete the table below to assist us to support you during your stay.

Prescription Drugs

Never Used

Currently Used

Previously Used

Date Last Used

Alcohol

Never Used

Currently Used

Previously Used

Date Last Used

Cannabis

Never Used

Currently Used

Previously Used

Date Last Used

Heroin

Never Used

Currently Used

Previously Used

Date Last Used

Cocaine

Never Used

Currently Used

Previously Used

Date Last Used

Other Drugs Please Specify

Date Last Used

Section 6: Criminal Convictions

Please list below all previous criminal convictions, charges pending or court appearances due.

Date

Offences Charged With

Sentence Received

Section 7: Previous Accomodation

Please list below where you have been living during the past 5 years, starting with your most recent address first.

Address

Date From

Date To

Reason for Leaving

Section 8: Sharing Information

Do you agree to Clifton House contacting any of the above agencies for information to assist us in considering your application?

Yes

Do you agree to Clifton Housing acting on your behalf with Birmingham City Council to claim for, and deal with all issues relating to your housing benefit payments to cover the costs of rent during your stay?

Yes

Section 9: Declaration

I declare that, to the best of my knowledge, the answers I have given to the questions on this form are true and Accurate. I understand that any false information provided by me will render my application liable to Disqualification. Action may be taken to recover tenancies obtained on the basis of false information.
I confirm that I have no objection to clifton house taking steps to verify the information contained in the Application, or seeking to obtain any further details, which may be considered relevant.

Applicants Name

Section 10: Ethnic Orgin

Clifton Housing Project aims to house those in need, regardless of their race, colour, national origin or culture. To enable us to monitor whether our policy is effective, please answer the following questions.

Your response will not affect your housing application. You may choose not to respond.

Which of the following groups do you think you belong to?

Asian or Asian British

Indian

Pakistani

Bangladeshi

Any other Asian

Black or Black British

Caribbean

African

Other

Chinese or Other

Chinese

Vietnamese

Thai

Mixed

White and Black Caribbean

White and Black African

White and Asian

White

British

Irish

European

Any Other Background

Don’t Know

Do Not Want to Answer

The information on this form will be treated in strictest confidence. Personal data which is held will be processed in line with the Data Protection Act 1998