Application For Housing

Referral Details

Date of Referral:

Referrer Name:

Referrer Contact Details:

Client Details

Name:

Age:

Contact Number:

Date of Birth:

NI Number:

Gender:

Nationality:

Ethnicity:

Next of Kin Name & Contact Details:

Housing Status

Please tick which is your current housing status:

Address History

Previous Accommodation:

Does the client have recourse to public funds/benefits?

NoYes

Does the client have a current/former offending history?

NoYes

Is the client on any medication?

NoYes

Does the client have any substance/alcohol misuse issues?

NoYes

Physical and Mental Health

Does the client have any physical health diagnosis/concerns?NoYes

Does the client have any mental health diagnosis/concerns?NoYes

Mental Health and Physical Health Concerns/Diagnosis:

Is the client working with any other agencies?

NoYes

Risk To Self - This List is Not Exhaustive

Nomad will treat all risk assessment information with sensitivity. Nomad will sometimes need to ask for more details about the risk. The safety of staff, visitors and other residents is paramount, therefore if the risk is identified as unmanageable the referral will be declined. Please tick all that apply:

Risk To Others - This List is Not Exhaustive

Nomad will treat all risk assessment information with sensitivity. Nomad will sometimes need to ask for more details about the risk. The safety of staff, visitors and other residents is paramount, therefore if the risk is identified as unmanageable the referral will be declined. Please tick all that apply:

Agency Involvement

What housing referrals have already been submitted?

Has a homelessness assessment and PHP been complete? (if so please attach to referral)

Known sleep site?

Declarations

By signing this form you are declaring that all the information you have provided on it is accurate to the best of your knowledge. If inaccurate or incomplete information is provided it may result in your client losing any subsequent accommodation. This application form will be kept on the service user’s file, to which the service user will have access. Any information you wish to be kept confidential must be recorded as “confidential third party information only”.

If form is sent electronically tick box

Signed:

Print Name:

Date: