Sheltered Housing Referral Form. Main Applicant s photos:

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1 Sheltered Housing Referral Form Photographs Please affix two recently taken passport sized photographs of the main applicant and the joint applicant (if applicable): Main Applicant s photos: Main Applicant Photo 1 Main Applicant Photo 2 Joint Applicant s photos: Joint Applicant Photo 1 Joint Applicant Photo 2 For use from: vember 2013 Page 1 of 9

2 For NHOPS s use only: Date Stamp: Sheltered Housing Referral Form All information will be treated as confidential. Failure to complete the whole form may delay the application process. Please complete the form CLEARLY. Agency Details This section is to be completed by the Voluntary Agency making the referral. Name of referral agency: Address of referral agency: Print Name: (Referral agent completing this form) Date: (DD/MM/YYYY) Contact Number(s): or, alternatively call: Address: Personal Details The rest of the form is to be completed with the main applicant. 1. Who is applying for sheltered accommodation? Main Applicant Joint Applicant Title First Name Surname Current Address Including post code Contact Number (Mobile Preferred) Main: Alternative: Main: Alternative: For use from: vember 2013 Page 2 of 9

3 Personal Details continued Date of Birth DD/MM/YYYY Age at the time of application Main Applicant Joint Applicant Gender Male Female Male Female What is the referrals National Insurance number? What is the referrals religion? What is the referrals main spoken language? Does the referral need an interpreter? Yes Please state any communication difficulties? Next of kin name: Next of kin address: Next of kin s telephone number (mobile preferred): Next of kin s relationship with the applicant: Current Housing Situation and Needs 1. What is the referrals current housing situation? Choose one only. Council tenant Homeowner/occupier Living in a Hotel or Hostel Living with family Living with friends fixed abode Renting from a housing association Renting from a private landlord Other situation If other situation, please specify: 2. Describe the accommodation that they live in: Bedsit/studio flat Bungalow Flat House Maisonette Room in a house For use from: vember 2013 Page 3 of 9

4 Current Housing Situation and Needs continued 3. If you have ticked ROOM IN A HOUSE, are there cooking facilities in their room? Yes N/A 4. Is their accommodation permanent or temporary? Permanent Temporary 5. What floor is their accommodation on? Choose from this drop down list... N/A 6. Is there a lift? Yes N/A 7. Do they have a bedroom for their own personal use? Yes 8. Is their accommodation in poor condition? (Close to uninhabitable) Yes 9. Have they been served with a legal notice to leave? Yes 9a. If Yes, when does this notice expire? DD/MM/YYYY YOU MUST ATTACH SUPPORTING DOCUMENTS TO THIS EFFECT. 10. What is their landlord s name? 11. What is their landlord s address? 12. What is their landlord s contact number? 13. If they are a HOMEOWNER/OCCUPIER is the property currently on the market or has it been sold subject to completion? YOU MUST ATTACH SUPPORTING DOCUMENTS THIS EFFECT Property is on the market to be sold Property has been sold (Subject to completion) For use from: vember 2013 Page 4 of 9

5 Housing History 1. Please complete the table to show all of the addresses where the main applicant has resided over the last three years starting with their most current address. It is very important that you state their reason for leaving/wanting to leave. Continue on a separate sheet of paper if you need more room: Date From MMM-YY Date To MMM-YY Full Address Type of Property Reason for leaving / wanting to leave Present or: Choose from this list... Other: Choose from this list... Other: Choose from this list... Other: 2. Have they ever been evicted from previous accommodation? Yes 2a. if Yes, please give details: Accommodation, Location and Preference 1. Please select which areas/schemes the referral will prefer to live in (select all that apply): Barnet Brondesbury Harrow Kingsley Court Avonhurst House Parkfield House Knightleas Court Haringey Kensal Green Kilburn Portland Place Purves Road Morland House Demacque Court Kingsbury Neasden Stonebridge Maple Lodge Arran Court Biko House Cherrylands Close Roberts Court Newcroft House Wembley Westminster Willesden Corsham House Mary Seacole House Beldanes Lodge Elsley Court Waterside Court Clovelly Court Rydal Court Pavitt Court For use from: vember 2013 Page 5 of 9

6 2. Would the referral consider self contained studio accommodation? This is a compact flat with one main room, a kitchen and bathroom facilities. Yes 3. Would the referral consider living in studio accommodation with shared facilities? Shared facilities refer to a communal bathroom and/or kitchen. Yes 4. if, please give their reason(s): Income, Employment and Assets 1. Is the referral employed? Yes 1a. if Yes, what is their occupation? 2. What is their weekly wage? 3. Are they in receipt of benefits? Yes 3a. if Yes, please give details in the table below: Name of Benefits Received Weekly Amount Length of time in receipt Years Month(s) Years Month(s) Years Month(s) Years Month(s) 4. Does the referral have any savings or investments? Yes 4a. if Yes, please give details in the table below: Type of savings/investments Amount 5. Has the referral had an application for Benefits rejected by the DWP (Department of Work and Pensions)? Yes 5a. if Yes, please give details: For use from: vember 2013 Page 6 of 9

7 Medical Support Needs and Care If relevant supporting documentation is not enclosed we will not be able to asses the main applicant s priority on medical grounds correctly. 1. Does the referral have a medical condition, disability or mental illness? Yes 2. If Yes, please give a short description of their medical condition: 3. Does the referral need any aids or adaptations in their accommodation? Yes 3a. if yes, please give details: 4. Does the main applicant use a mobility aid? (i.e. a wheelchair, Zimmer frame etc) Yes 4a. if yes, please give details: 5. Does the referral have support needs related to the use of drugs and/or alcohol abuse? Yes 5a. if yes, are they being supported with these needs? Yes 5. If Yes, please give details of their support group or agency below: 5b. What is their support group or agency s name? 5c. What is their support group or agency s address? 5d. What is their support group or agency s contact number(s)? Main: Alternative: 5e. What type of support is being provided? 5f. How often is the support provided? For use from: vember 2013 Page 7 of 9

8 Consent and Authorisation Please confirm by signing and dating below that all of the information provided within this referral form is accurate, and that you agree to us contacting your sources for further information. Please note that any incomplete referral form will cause a delay in potentially being able to house you, so it is in your best interest to submit as much detail and relevant supporting documents as is possible, to give you the best opportunity. (You will need to print this page in order to sign it). Signed: (Main Applicant) Date: (DD/MM/YYYY) Print name: (Main Applicant) Signed: (Referral agent completing this form) Date: (DD/MM/YYYY) Please ensure that you use the Enclosed Supporting Documents Checklist on the next page. For use from: vember 2013 Page 8 of 9

9 Enclosed Supporting Documents Checklist Please ensure that you provide copies of all relevant supporting documents issued within the last 3 months in order to support your referral form. Failure to do so will render your referral form incomplete, causing delays with the form being processed. Proof of identification Passport (Photo Page) Enclosed N/A Birth Certificate Enclosed N/A Freedom Pass Enclosed N/A Proof of income Bank Statement (Within the last two months) Enclosed N/A Letter from the DWP (Most recent) Enclosed N/A Letter from the Pension Services (Most recent) Enclosed N/A Supporting medical evidence Letter from your GP Enclosed N/A Letter from the hospital Enclosed N/A Confirmation of housing situation Tenancy Agreement Enclosed N/A tice of eviction/tice of seeking possession Enclosed N/A Confirmation of sale of property (Solicitors letter) Enclosed N/A Supporting Statement From a support worker, relative, landlord etc Enclosed N/A Please return this completed referral form and all of the enclosed supporting documents to the following address: Network Homes Older Persons Service 8 Fulton Road Wembley Middlesex. HA9 0NU Or NSOPSReferrals@networkhomes.org.uk Should you have any queries about the referral form, please call: For use from: vember 2013 Page 9 of 9