Organisation Making the Referral *
Organisation Contact Name *
Organisation Contact Email *
Title * Please selectDrMissMrMrsMsMx
First Name *
Last Name *
Referral Type * Please selectSupported AccommodationDirect ReferralEmergency bed referralMother and babyRough Sleeper ProjectsYoung Persons Project
Select Project * Please selectWandsworthHammersmith & FulhamKensington & Chelsea
Mobile Number
Email (If you do not have one, leave blank)
Date of Birth Known * Please selectYesNoClient did not wish to disclose
Date of Birth *
NI Number Known * Please selectYesNo - client does not know itNo - client does not have oneClient did not wish to disclose
Gender Please selectFemaleMaleA genderedGenderfluidGenderqueerGender non-conformingIntersexNon-binaryThird genderDid not askClient did not wish to disclose
Sexual Orientation Please selectAsexual / AceBisexualGayHeterosexualLesbianPansexual / PanQueerUnsureOtherDid not askClient did not wish to disclose
Primary Nationality * Please selectAfghanAlbanianAlgerianAmericanAndorranAngolanAnguillianCitizen of Antigua and BarbudaArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianCitizen of Bosnia and HerzegovinaBotswananBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseColombianComoranCongolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominican Citizen of the Dominican Republic DutchEast TimoreseEcuadoreanEgyptianEmiratiEnglishEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadianGuamanianGuatemalanCitizen of Guinea-BissauGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianCitizen of KiribatiKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianScottishSenegaleseSerbianCitizen of SeychellesSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt LucianStatelessSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks and Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenCitizen of VanuatuVenezuelanVietnameseVincentianWallisianWelshYemeniZambianZimbabweanDid not askPrefers not to say
Ethnic Origin * Please selectAsian / Asian British: BangladeshiAsian / Asian British: ChineseAsian / Asian British: IndianAsian / Asian British: OtherAsian / Asian British: PakistaniBlack / Black British: AfricanBlack / Black British: CaribbeanBlack / Black British: OtherMixed / multiple: OtherMixed / Multiple: White & AsianMixed / Multiple: White & Black AfricanMixed / Multiple: White & Black CaribbeanOther Ethnic group: ArabOther Ethnic group: OtherWhite: English / Welsh / Scottish / Northern Irish / BritishWhite: Gypsy or Irish TravellerWhite: IrishWhite: OtherDid not askClient did not wish to disclose
Preferred Language * Please selectEnglishAcholiAlbanianAmharicArabicBengaliBritish Sign Language (BSL)BulgarianCantoneseCzechDariEritreanEstonianFarsi / PersianFrenchGermanGreekGujaratiHungarianItalianKrioKurdishLatvianLingalaLithuanianMandarinNdebelePashtoPolishPortuguesePunjabiRomanianRussianSerbo-CroatSlovakianSlovenianSomaliSpanishSwahiliSwedishTamilTigreTigrinyaTurkishUrduVietnameseWelshYorubaDid not askClient did not wish to disclose
Translator Required YesNo
Religion Please selectAgnosticAtheistBuddhistChristian (all denominations)HinduJewishMuslimSikhAny other religionNot sureNo religionDid not askClient did not wish to disclose
Immigration Status Please selectUK nationalEEA nationalAsylum appellantAsylum seekerBritish citizen + failed HRTDiscretionary leave to remain (DLR)EEA citizen + failed HRTExceptional leave to remain (ELR)Failed asylum seekerHumanitarian protection (HP)Indefinite leave to remain (ILR)Limited leave to remainLimited leave to remain + NRPFOverstayerPre-settled statusRefugee Settled statusOtherDid not askClient did not wish to disclose
Immigration Status Other
Marital Status * Please selectMarriedWidowedSeparatedDivorcedSingle
Food Allergies or dietary requirements
Applicants Local Connection Please selectBarking & DagenhamBarnetBexleyBrentBromleyCamdenCity of LondonCroydonEalingEnfieldGreenwichHackneyHammersmith & FulhamHaringeyHarrowHaveringHillingdonHounslowIslingtonKensington & ChelseaKingston upon ThamesLambethLewishamMertonNewhamRedbridgeRichmond upon ThamesSouthwarkSuttonTower HamletsWaltham ForestWandsworthWestminster
Referral Officer Details - Please include details of the professional/volunteer who is making this referral. Referral Agency email address. A copy of the responses will be emailed to this address
Referral Agency Telephone
Relationship to Applicant Please selectHomeless CharityProfessionalLocal Authority Housing ProfessionalSupporting Agency ProfessionalPhysical or Mental Health Practitioner ProfessionalOther Housing Provider
Entitled to housing benefit YesNo
Applicant registered on LA housing list YesNo
If yes, date registered
If yes, registration number
Applicant with a statutory duty owed Please selectFound statutorily homeless by a housing authority and not owed a homelessness dutyFound statutorily homeless by a housing authority and owed a homelessness dutyNot found statutorily homeless by a housing authority but considered to be homeless by service provider
Next of Kin *
Relationship to Applicant * Please selectAuntBoyfriendBrotherCarerCousinDaughterDaughter-In-LawFatherFather-In-LawFriendFoster FatherFoster MotherFoster ParentGirlfriendGranddaughterGrandfatherGrandmotherGrandsonGuardianHusbandMotherMother-In-LawNeighbourNephewNieceOtherParentPartnerResidentSisterSonSon-In-LawStepdaughterStepfatherStepmotherStepsonUncleWife
Next of Kin Contact Number *
Next of Kin Email Address *
How long have you known the applicant?
Reason for application
Are you currently homeless? YesNo
Present Accommodation * Please selectProbation hostelBed and breakfastDirect access hostelFoyerHomeless ShelterHome office Asylum SupportHospitalHousing association general needs tenancyHousing for older peopleLiving with familyLiving with friendsLocal authority temporary accommodationLocal authority general needs tenancyMobile Home / CaravanOwner occupation (Low cost home ownership)Owner occupation (Private)Prison Private sector tenancyResidential care homeRough SleepingStaying with friendsStaying with familyShort life housingSupported housingTied housing or rented with jobWomen’s refugeYoung people leaving careOther
Main reason for leaving last settled home Please selectEnd of assured shorthold tenancy - no faultEnd of assured shorthold tenancy - eviction or tenant faultEnd of fixed term tenancy - no faultEnd of fixed term tenancy - eviction or tenant faultDischarged from long stay hospital or similar institutionDischarged from prisonLeft home country as a refugeeLoss of tied accommodationAsked to leave by family or friendsDeath of household member in last settled homeRelationship breakdown (non-violent) with partnerMoving nearer to family, friends or schoolMoving nearer to workDomestic abuse - previous joint tenancy with partnerDomestic abuse - otherHate crimeRacial harassmentOther problems with neighboursCouldn't afford tenancy renewal feeCouldn't afford rent increaseCouldn't afford rent or mortgage - employmentCouldn't afford rent or mortgage - welfare reformsCouldn't afford rent or mortgage - otherRepossessionProperty unsuitable - overcrowdingProperty unsuitable - ill health or disabilityProperty unsuitable - poor conditionMoving to supported accommodationMoving to independent accommodationUnder occupation - no incentiveUnder occupation - offered incentive to downsizeTenant prefers not to sayDon't know
Date from:
Date to:
Address:
Landlord details:
Employment status * Please selectUnemployedWorkingPart Time WorkingFull time Student
Income (Check all that apply) Universal CreditEmploymentNo Recourse to Public Funds
Support Needs Mental HealthPhysical HealthOffendingSubstance & Alcohol useEducation, Training & EmploymentHomeless In Need Of SupportDomestic ViolenceOther
Do You Receive Support From Other Organisations / Professionals?
Relationship to any current resident YesNo
Proof of ID attached YesNo
Proof of income attached YesNo
Upload Files ID * (max upload size 4mb)
Proof of Income (max upload size 4mb)
If no proof of income is available, please provide statement or written evidence to confirm this
Mental Health Report (max upload size 4mb)
GP Report (max upload size 4mb)
Other Document (max upload size 4mb)
