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Home
Care Services
Domestic Violence
Drugs and Alcohol Issues
Homelessness
Mental Health Issues
Vulnerable Adults
Referrals
Landlords
About Us
News & Articles
Contact Us
0121 377 6780
Online Referral
Thank you for completing the online referral form. We will respond to you shortly.
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Sections indicated with * are required.
SECTION 1 - REFERRAL AGENCY DETAILS
*Referral Agency
*Email
*Landline Number
Mobile Phone Number
*Reason for Referral
SECTION 2 - APPLICANT DETAILS
Title
Applicant Name
Address
Postcode
D.O.B
Gender
Contact Number
N.I. Number
Benefit Status
Immigration Status
Date of Entry to UK
Ethnicity
Next of Kin (& Relationship)
Next of Kin Address
Next of Kin Contact Number
SECTION 3 - PREVIOUS ADDRESS HISTORY (INCLUDING SUPPORTED ACCOMMODATION)
Address
Dates / Duration
Type of Occupancy, i.e. Private, Supported
Reason for Leaving, i.e. Arrears, ASB
SECTION 4 - APPLICANT MEDICAL BACKGROUND / HISTORY
Social Worker/ CPN/ Probation Officer or Other Relevant Professional/s
Address (If Applicable)
Has Client Ever Been: Detained / Sectioned Under The Mental Health Act?
.
Yes
.
No
If Yes, Please Provide Details:
SECTION 1 – REFERRAL AGENCY DETAILS
Address
Physical Health History
Present Medication and/or Treatment
Criminal Convictions/ Community Orders (This Information Must Be Provided)
Any Other Relevant Infomation
SECTION 5 - SUPPORT GROUP / SUPPORT NEEDS
Support Group Y/N
Support Needs: Please Provide Details of Level and Type of Support Required
Mental Health Problems
.
Yes
.
No
Single Homeless with Support Needs
.
Yes
.
No
Primary Health Care, Mental Health or Drug/Alcohol Services
.
Yes
.
No
Accommodation / Housing
.
Yes
.
No
Domestic Violence/Abuse
.
Yes
.
No
Other (Please specify)
.
Yes
.
No
SECTION 6 - AUTHORISATION - APPLICANT
I give my consent to the disclosure of this information for the purpose of finding accommodation and to the disclosure of any supplementary information attached for housing purposes.
I give my permission for the outcome of this referral to be explained to the referral agency
I agree to participate in a support package including support planning and assessment
*Applicant
*Date
.
*Please check the box to consent to the above
SECTION 7 - AUTHORISATION REFERRAL AGENCY
*Name of Person Making Referral
*Date
Position in Company
.
*Please check the box to consent to the above
SECTION 7 - SUPPORTING DOCUMENTATION / ADDITIONAL INFORMATION
Please List Documents To Be Attached / Additional Information:
PLEASE NOTE: SUCCOUR HAVEN CIC IS AN EQUAL OPPORTUNITIES HOUSING PROVIDER.
HOWEVER WE RESERVE THE RIGHT TO REFUSE REFERRALS WITH A HISTORY OF ARSON (INSURANCE REGULATIONS) AND SEX OFFENCES
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