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Homeless Referral Form

Homeless Referral Form

Use this form to make a referral for a homeless client

Homeless Referral FormEliranda2023-11-15T13:58:10+00:00

Thank you for your interest in EliRanda Hope Housing Community Interest Company.

Please find here, more information about the support we offer

You can submit a referral via the form below, or you can call us directly on 07842 700672 or +44 (0)208 1643 122.

If you are a professional or making a referral on behalf of someone else - Everything below that concerns the person about whom you are making the referral.

"*" indicates required fields

Step 1 of 8 - Referrer Details

12%
Documents required:
  • Proof of ID (Passport, Drivers License, Learners Drivers License, Jail License Letter, etc)
  • Proof of Benefits
  • Proof of National Insurance number
  • 1 month bank statement
  • If in employment (please provide payslips)
    • "*" indicates mandatory fields

    Page 1 - Referrer Details

    Name of Referrer*
    Referrer Email*
    Organisation Address

    Page 2 - Client Info

    Name Of Client*
    Date of Birth*
    Current Residential Status*
    Confirm if this number is available on WhatsApp
    Client Email Address*
    Current Home Address*
    What type of benefits received*
    Client who are not self funding must be eligible for State Benefits / Public Funds
    Do they attend Job Centre appointments
    If applicable
    Does Client have a GP*
    If "No GP", We will register client with a local GP when accommodation has been found.
    GP Address*

    Page 3 - Next of Kin

    Next of Kin Name*
    Address of Next of Kin*

    Page 4 - Medical History

    Does the client have any medical condition(s)*
    Does the client have any diagnosed mental health conditions*
    Does the client believe they suffer from or are experiencing any mental health conditions or symptoms*
    Does the client give their consent for their diagnosed or undiagnosed mental health conditions to be disclosed by any mental organisations so adequate support / medications and therapy to be provided for them*
    Does The Client suffer from any of the following*
    If Risk of Suicide, Please State Risk Level*
    10 = Extremely High Risk - 1 = Very Low Risk
    Behavioural Issues*

    Page 5 - Support requirements details

    Client requires support for*
    Please tick all that apply.

    Page 6 - Criminal Justice Contact

    Is client currently on a Prison License*
    If Yes please attach a copy of prison licence on the last page.
    Please confirm the Date licence will end*
    Is client known to Probation Service / National Probation Service*
    Is the client on a tag*
    Confirm if the Referrer is the Probation Service*
    Email Address of Probation Officer*
    List details of all Offences*
    Details of offence
    Custodial sentence
    Length of Sentence
    Where was sentence served
     
    click + to add more offences
    Details of Drug Abuse etc.

    Page 7 - Risk Assessment

    Please tick all that are relevant

    Risk To Self

    Neglecting Self*
    Abuse by Others*
    Drug Misuse*
    Risk of Suicide*
    Alcohol Misuse*
    Self Harm*
    Anti Social Behaviour*
    Getting Lost / Disorientated*
    Accident Prone*
    Mobility Issues (climbing stairs)*
    Visual Impairment*
    Financial Abuse*
    Environmental Risk*
    Non-engagement with Staff*
    Risk of Continuous Homelessness*
    Risk of Ingesting Substances*
    Risk of misplacing of keys*
    Lack of Road Sense*
    Failure to take Medication*
    Other Risk to Self?*

    Risk To Others

    Risk of Violence to Family Members*
    Risk of Violence to Staff*
    Risk of Violence to Other Residents*
    Risk of Violence to the Public*
    Risk of Violence from a Third Parties*
    (Gang affiliations, ex-partner, etc)
    Threat to Children*
    Sexual Misbehaviour*
    Inappropriate Behaviour*
    Other Risk to Others?

    Risk On Transport

    Risk of Not Wearing seatbelt*
    Risk with Lift on the Bus*
    Risk with navigation / Road Sense*
    Other Risk on Transport

    Risk related To Property

    Risk of Arson*
    Damage to property*
    (including fire and safety equipment)
    Risk of Theft*
    Risk of maintaining a tenancy*
    Risk of Abandoning Property*
    Risk of interference with Gas/Electricity*
    Other Risks to Property?

    Page 8 - Upload Documents and Consent

    Drop files here or
    Accepted file types: pdf, jpg, png, gif, webp, jpeg, tiff, doc, docx, , Max. file size: 16 MB.
      ( Any of these will be accepted - Passport, Drivers license, Learners Drivers license , Citizenship card, Prison release letter, Jail license letter )
      Drop files here or
      Accepted file types: pdf, jpg, png, gif, webp, jpeg, tiff, doc, docx, , Max. file size: 16 MB.
        Drop files here or
        Accepted file types: pdf, jpg, png, gif, webp, jpeg, tiff, doc, docx, , Max. file size: 16 MB.
          Drop files here or
          Accepted file types: pdf, jpg, png, gif, webp, jpeg, tiff, doc, docx, , Max. file size: 16 MB.
            Drop files here or
            Accepted file types: pdf, jpg, png, gif, webp, jpeg, tiff, doc, docx, , Max. file size: 16 MB.
              I give my consent for the information that I have given to be shared internally and between EliRanda Hope Housing CIC and relevant agencies in order to access accommodation and services in relation to my identified needs.*
              It has been explained to me that this information will be held on a database, will remain confidential and will not be shared with any other agency without first seeking my permission.*
              I understand the only exception to this will be where EliRanda Hope Housing CIC has serious concerns about the personal safety of myself or others. For example, where there are concerns including if I may be contemplating suicide or self harm, there is a genuine threat of violence against others, or where staff are summoned by a Court Order to give evidence.*
              Thank you for completing this form - we will email you a copy of the referral information and be in touch soon to arrange an interview where we can check Identification Documents and discuss further support needs and options available. Upon successful admission to our Project or admission into our tenancy, EliRanda Hope Housing CIC undertakes to provide a suitable accommodation as stipulated by Law. Should a client decide to move on because they no longer find our accommodation suitable we give no undertaking to offer them an alternative accommodation
              This field is for validation purposes and should be left unchanged.
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              Gor Ray House
              758 Great Cambridge Road,
              Enfield,
              London,
              EN1 3GN

              02081 643 122

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