Concrete

What is the name of the person you're referring?

What is their current address, last address or postal address?

What is their address history for the last three years?

What is their home tenure?

What is their telephone number?

What is their email address?

What is the date of birth of the person you are referring?

What is the national insurance number of the person you are referring?

What is the ethnic origin of the person you are referring?

Why is this person currently homeless or threatened with homelessness?

How long do they believe they have left in their current accommodation, or how long have they been homeless?

What is the name of the person or organisation that has caused them to leave?

Please provide further detail around their housing and personal circumstances, adding any other relevant information.

Does this person currently work or are they in receipt of benefits?

If they receive benefits, please advise what benefits they are in receipt of and how much they receive.

Does this person currently have any physical health needs, medical or mobility problems?

Please list any medical issues or vulnerabilities that this person has.

How do their health problems affect them, and what does it prevent them from doing?

Do they require support with any area of their life?

Do they have any support agency or worker currently working with them?

Do they have any problems in relation to drink or drugs?

Do they have any convictions? If yes, please list the offence, conviction date and sentence for any household members.

As the referrer, please tell us your name and contact number so that we can get in touch.

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