Wolverhampton Homes | Homeless - duty to refer form

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Homeless - duty to refer form

Duty to refer

If you are a specified public body, you can use this form to refer consenting people who you believe to be homeless or threatened with homelessness. If you have any queries, please email DutytoRefer@wolverhamptonhomes.org.uk

Referring agency details

Consent for storing submitted data *

Yes, I give permission to store and process my data

Are you a public body with a duty to refer? *

Yes

Type of public body e.g. prison, hospital etc. *

Name of your organisation *

Is your client aged 16 or 17? *

Yes

Your post or role *

Full name Enter your full name

Phone number Enter a UK landline or mobile number

Email address Enter an email address

The person being referred

Your client's full name *

Your client's date of birth *

Your client's gender *

Your client's nationality *

Your client's address *

Your client's postcode *

Your client's national insurance (NI) number *

Is your client currently homeless? *

Yes

When will your client be without accommodation? *

Does your client live in the city of Wolverhampton? *

Yes

Why are you referring this client? *

Does your client have somewhere safe to stay tonight? *

Yes

Has your client been referred by social services to apply for housing as part of their assessment process? *

Yes

Has your client given you consent to refer them to us? *

Yes

What is your client's preferred contact method? *

Please enter your client's phone number/s

Please enter your client's email address

Do you agree to help your client with initial contact to help their housing application or assessment, if required? *

Yes

Has your client been referred elsewhere? *

Yes

Does your client want us to contact any other person as part of their referral to us?

Yes

Client support needs

Is your client's safety at risk? *

Yes

Is your client leaving one of these types of accommodation? *

Is your client experiencing any of the following? Select all that apply *

Is pregnant

Has a dependent child or children

Has support needs

Has physical needs due to a disability

Has health or medical needs

Is vulnerable due to their age

Has a physical disability

Has mental health issues

Has an impairment

Currently has substance misuse difficulties e.g. alcohol or drugs)

Has a history of substance misuse difficulties e.g. alcohol or drugs)

Is experiencing domestic violence or abuse

Has experienced domestic violence or abuse within the last 12 months

None of these apply

Please provide details of any relevant medical, health needs or special/support needs of your client

How many people are in the household you are referring to us (including the applicant)?

Number of adults *

Number of children *

Declaration * I / we confirm that we are referring the person / household to the City of Wolverhampton Council and Wolverhampton Homes as we believe they are at risk of homelessness and confirm they have given their consent to this referral.

Declaration

Please confirm you're not a robot... * Please tick the box to proceed

Privacy information

The council is under a duty to protect public funds and may use the information held or provided by you for the prevention and detection of fraud. For more information on how we use your data to do this please read our privacy policy.

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