Housing Support Service
Referral Form
Referral Date
/
Day
/
Month
Year
Referrer Details
First Name
Last Name
Role:
District Council
Phone Number
Please enter a valid phone number.
Email
example@example.com
Client Details
Client name
*
First Name
Last Name
Phone Number
Email address
example@example.com
Date of birth
*
/
Day
/
Month
Year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How would you describe your identity?
Female
Male
Trans
Prefer not to say
Pronoun
Self Describing
Non-binary
Prefer not to self-describe
Does your client consent to us contacting them by:
Text
Email
Phone
Letter
Type of Support Required
Preventative - dependent service users in or about to enter crisis likely to impact tenancy maintenance
Maintenance - dependent service users recently moved to secure accomodation
Please provide details
Substance of choice and details of use
Other important relavent information - please detail and physical/mental health concerns, safeguarding conerns (e.g. children) or details of any incident that have led to the referral
Any other assistance needed? (e.g. translation of access needs)
Any identified risks?
Other Relavent Information?
Debt
Rent arrears
Court Order/Possession Order obtained to evict from Home
Licence revoked – 7 days to move out of temp/shared accommodation
Please give details:
Submit
Should be Empty: