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Applicant must meet all listed criteria
Not statutory homeless Age 18+ Has recourse to public funds Local Birmingham connection (lived in Birmingham minimum 2 years) Has housing need Mental Health need Not living in supported accommodation
And experiencing two or more:
Mental ill healthSubstance useExclusion or risk of exclusion from services
—Please choose an option—ACAPASH HubCommunity Mental Health TeamCriminal justice agenciesDA HubExempt Sector Accommodation ProviderHealth service/GPHousing Options TeamInternal transferNeighbourhood Network ServicesOffenders HubOther Outreach ServiceSelf-referral/direct applicationSocial Housing Accommodation providerSocial ServicesSubstance use servicesVoluntary organisationYouth HubOther
Referrer name
Referrer role
Date referral made
Organisation
Telephone number
Email address
In what capacity do you know the person you are referring?
How long has the person been known to your services?
Title —Please choose an option—MrMrsMissMsMxOther
Name
Date of birth
Please choose age category of person —Please choose an option—18-2425-4950-5960+
First Language
Interpreter required —Please choose an option—YesNoRefused to answer
Client's address
Postcode (Required)
Is it safe to write to this address? —Please choose an option—YesNoDoes not wish to disclose
Contact telephone number
Can we call at any time? If no, please detail —Please choose an option—YesNo
Can we email this address? —Please choose an option—YesNo
Next of Kin details (name, relationship, address, phone, email)
Multiple selections available
Full time employmentPart Time employment (less than 24 hrs per-wk)Job SeekersUniversal CreditLong term sick / disabilityNot seeking work National insurance number (if known)
Is anyone within the household pregnant? If yes, expected delivery date —Please choose an option—NoYes Are there any pets? —Please choose an option—NoYes
At least one is required
Support to access suitable accommodationSupport to sustain current accommodation
Housing need / additional information *
BCC TenancyPrivate rentingSofa surfingSupported AccommodationEviction noticeRent arrearsTemporary accomodationProperty doesn't meet needs
To better manage or have improved my mental healthTo better manage or have improved my physical healthTo improve (self-reported) wellbeing satisfaction levelsTo register with a GPTo register with a dentistTo be safe and wellTo no longer self-harmTo access primary health careTo access specific health programmes including vaccinationsTo eat a healthy dietTo stop smoking or have accessed support to do soTo stop drinking or reduced my alcohol intakeTo stop or accessed support to stop taking nonprescription drugsTo participate in regular exerciseTo no longer feel digitally excluded and can access accredited data sources to make informed choices
To develop life skillsTo maintain my accommodation, including paying rent and billsTo maintain my tenancy by overturning an eviction noticeTo secure short term accommodationTo secure long term accommodation
To reduce my overall debtTo access to eligible benefitsTo maximise my income from accessing available grants and other fundingTo participate in or obtained paid workTo participate in education or trainingTo manage my finances and budgets
To establish contact with services, friends, and familyTo participate in community and/or religious and faith activitiesTo have someone to talk toTo volunteer or participated in work experienceTo integrate with and become part of a communityTo no longer feel alone
Please tick all that apply
Gain access to other servicesSupport to stay safeOther
Please describe
We require full details of any identified risks and current safeguards or triggers.
Substance useDomestic abuseMental healthPhysical health/disability
Please provide detail:
—Please choose an option—NoneMobilityVisual impairmentHearing impairmentProgressive/chronic illnessMental healthLearning disabilityAutistic spectrum conditionOtherDoes not wish to disclose
As part of safeguarding, to allocate staff appropriately, please confirm:
Is the referred individual known to police, probation, or MAPPA? —Please choose an option—YesNo
If known, select offence categories and Yes/No:
Violent offences —Please choose an option—YesNo
Sexual offences —Please choose an option—YesNo
Offences against children —Please choose an option—YesNo
If yes to any, provide further information on risks identified and any agencies involved
Are there any safeguarding concerns? If yes, provide details and confirm if there is current Social Care and Health involvement
Domain
Worker name
Contact details
Social services
Mental health services
Substance use service
Probation/offender manager
Other
Ethnicity —Please choose an option—Asian PakistaniAsian BangladeshiAsian ChineseAsian IndianAsian otherBlack AfricanBlack CaribbeanBlack BritishBlack otherGypsy/Romany/TravellerMixed White AsianMixed White BlackMixed otherOther ethnic groupWhite BritishWhite IrishWhite otherDoes not wish to disclose Nationality Marital Status —Please choose an option—SingleSingle PregnantSingle Lone ParentCouplesCouple ExpectingDoes not wish to disclose Gender —Please choose an option—MaleFemaleTranssexualCis-genderNon-binaryOtherDoes not wish to disclose Sexuality —Please choose an option—BisexualGay manLesbianHeterosexualDoes not want to disclose Religion —Please choose an option—BuddhistChristianHinduJewishMuslimSikhNoneOther religionDoes not wish to disclose
Referral type Self-referralProfessional/third party referral
Self-referral:
I consent to my personal information being shared to receive housing support services and understand I may withdraw consent.
Professional/third party referral:
In line with GDPR 2018 I confirm this referral has been discussed with the client and they agreed to it being made.
Client consented to process their information. Please tick to confirm
Name of Applicant
Signature
Date
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