Online Referral Form

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 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
Section 1: Applicant Details
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
Support Team A
Support Team B
Section 3: Benefits Status
Please complete the following to show which benefits you are currently receiving or have applied for. Please ensure dates and amounts are completed.
Section 4: Health and Medicine
Section 5: Drug and Alcohol Use
Please complete the table below to assist us to support you during your stay.
Section 6: Criminal Convictions
Please list below all previous criminal convictions, charges pending or court appearances due.
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.
Date From
Date To
Reason for Leaving
Section 8: Sharing Information
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.

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?

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