Referral Application Form

Name*

First Last

Date of birth (DD/MM/YYYY)*

Contact Number*

Email*

Sex at birth*

Current Address*

Street Address City State / Province / Region ZIP / Postal Code

Previous Addresses*

Please enter your full previous addresses including the street number, street name, city and postcode. Please also state which Housing Association or provider you were with and the duration of the accommodation.

Ethnicity*

Your Religion/Beliefs*

Sexual Orientation*

If you have any disabilities (physical i.e. health condition) or mental health illness, please let us know below*

Disabilities can include physical or mental impairment as well as a long-term health condition.

If you have any additional communications needs, please let us know below.*

This could be things such as Braille, Large Print, Audio-tape, Translation services / British Sign Language or Makaton Sign language

National Insurance Number*

Current Benefits*

If you are on benefits, please state which date these benefits started on (DD/MM/YYYY)

Do you have a worker assigned to you?

Please select which of the following workers are assigned to you. This could be a social worker, support worker, mental health support or drug support worker.

Social Worker

Support Worker

Mental Health Support

Drug Support Worker

Probation Officer

I do not have an assigned worker

If you do have an assigned worker, please can you provide their name, phone number and email address*

Do you suffer from a mental health illness?*

If you answered yes to having a mental health illness, please kindly explain in more detail below

Do you have drug related problems?*

If you do answered yes to drug misuse problems, please kindly explain in more detail below

Do you have any criminal offences or convictions?*

If you have been convicted of a criminal offence or having pending court appearances, please give the details below.*

Are you homeless?*

If you answered yes to being homeless, please explain why below

Do you feel you have a good understanding of English/Western culture?*

We ask this so that we may understand the level of support you may need or if you need any additional support to help you integrate into society.

Are you looking for permanent accommodation?*

We ask this so that we may understand the level of support you may need or if you need any additional support to help you integrate into society.

I acknowledge that I have read the terms, conditions and criterias as highlighted by the referral application guide*

Yes

I give my full consent to S4 Housing to use the information I have provided in this application form and understand it will only be used by S4 Housing for the purpose of providing their support services.*

Yes

Referral Application Form

Referrel Application Form

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