This service is for Birmingham citizens over the age of 25, and accepts professional referrals only.

If you are a citizen experiencing homelessness, or are at risk homelessness in the next 56 days, contact Birmingham City Council’s Homeless Options Centre on 0121 303 7410.

Should you require emergency accommodation outside of office hours, please contact BCC’s Out of Hours Duty Team on 0121 303 2296.

Criteria and eligibility

Applicant must meet all listed criteria.

Not statutory homeless
Age 25+
Has recourse to public funds
Local Birmingham connection (lived min. 2 years)
Is a single adult/couple Single adultCouple
Repeated periods of homelessness (within 10 years)
Has no dependent children

AND experiencing two or more of the following:

Mental ill healthSubstance useOffending/convictions (within 10 years)Exclusion or risk of exclusion from services

Referral source

—Please choose an option—Community Based Advisor (GAIN)BCC Adult Social CareHealth service providerOther

Referrer name
Referrer role
Date referral made*
Organisation
Telephone number
Email address

In what capacity do you know the citizen you are referring?
How long has the citizen been known to your services?

Citizen details*

Title —Please choose an option—MrMrsMissMsMxOther
Name*
Date of birth*
Age band —Please choose an option—25-4950-5960+
First language
Interpreter required —Please choose an option—YesNo

Full address (including postcode)*
Is it safe to write to this address? —Please choose an option—YesNo
Contact telephone number
Can we call at any time? If no, please detail. —Please choose an option—YesNo

Email address
Can we email this address? —Please choose an option—YesNo

Economic status

Select all that apply:

Full time employmentPart Time employment (less than 24 hrs per‑wk)Job SeekersUniversal CreditLong term sick / disabilityNot seeking work
National insurance number (if known)

Household details

Is this a joint referral? —Please choose an option—YesNo

Is anyone within the household pregnant? If yes, expected delivery date —Please choose an option—YesNo
Expected delivery date

Are there any pets? —Please choose an option—YesNo

Support needs

Health & Wellbeing (select all that apply)

NoneTo 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 access support to do soTo stop drinking or reduce my alcohol intakeTo stop or access support to stop taking non-prescription drugsTo participate in regular exerciseTo no longer feel digitally excluded and access accredited data sources to make informed choices

Living independently (select all that apply)

NoneTo 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

Financial wellbeing (select all that apply)

NoneTo reduce my overall debtTo access eligible benefitsTo maximise my income from accessing available grants and other fundingTo participate in or obtain paid workTo participate in education or trainingTo manage my finances and budgets

Socially active (select all that apply)

NoneTo establish contact with services, friends, and familyTo participate in community and/or religious and faith activitiesTo have someone to talk toTo volunteer or participate in work experienceTo integrate with and become part of a communityTo no longer feel alone

Additional information

Housing status / additional information

General needs tenancy (Social housing, private rented, etc.)Living with family/friendsSofa surfingSupported Accommodation (Local Authority funded)'Exempt' AccommodationHMO (House of multiple occupancy)Temporary accommodation (local authority)Approved premises (Criminal Justice)
Please detail

Information on risk

Substance use —Please choose an option—Very HighHighMediumLowNone
Domestic abuse —Please choose an option—Very HighHighMediumLowNone
Mental health —Please choose an option—Very HighHighMediumLowNone
Physical health/disability —Please choose an option—Very HighHighMediumLowNone
Risk to self —Please choose an option—Very HighHighMediumLowNone
Risk to others —Please choose an option—Very HighHighMediumLowNone
Please detail further information on all risks here

Criminal justice

Offending history including recent offences —Please choose an option—YesNo
Known to police, probation, or MAPPA? —Please choose an option—YesNo

If yes, please select offences:

Violent offencesSexual offencesOffences against children
Further information on risks and any agencies involved

Safeguarding

Are there any safeguarding concerns? —Please choose an option—YesNo
Safeguarding details
Is there current Social Care and Health involvement? —Please choose an option—YesNo

Organisations involved

Please provide contact details for professionals working with the citizen.

Equal opportunities monitoring

There are non‑disclosure options if required.

Ethnicity —Please choose an option—Asian BangladeshiAsian ChineseAsian IndianAsian PakistaniAsian 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—MaleFemaleTransgenderCis‑genderNon‑binaryDoes not wish to disclose

Sexuality —Please choose an option—HeterosexualGay manLesbianBisexualDoes not want to disclose

Religion —Please choose an option—BuddhistChristianHinduJewishMuslimSikhOther religionNoneDoes not wish to disclose

Declaration*

In line with GDPR 2018, please confirm you have discussed the referral with the citizen and they have agreed to it being made.

I confirm the citizen has agreed to this referral.

Consent*

Citizen consented to process their information. Please tick to confirm.

I confirm the citizen has consented to their information being processed.

Name of Applicant
Date

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