Initial Referral Form (CONFIDENTIAL)
Referral Criteria:
· Living in Liverpool City Council’s Catchment area
· A homeless family excluded from the social housing sector
· A family renting in the private sector
· At risk of becoming homeless
· In need of housing support
Date of referral1. Details of referred family (parent/ carer)
Surname: / Forename(s):
Address:
Date of Birth: / National Insurance No:
Home Telephone No: / Mobile No:
Is there a preferred time to contact the client, if so when:
Is the client a / Social
Tenant o / Private Tenant o / Homelesso /
Homeowner o Other o
Please state:
Name of Landlord if known:
2. Reason for Referral
Please explain what difficulties they are having in their home (risk of losing tenancy, first tenancy, resettlement, debt/ budgeting, rent arrears, welfare benefits, lacking furniture, harassment/ nuisance, overcrowding, general coping skills and anything else of relevance
If homeless, has a homeless duty been accepted? Yes o No o Pending o Not known o
3. Details of the family members or others in the household
Name / DOB / Gender / Support Needs Yes/ No (please state)
4. Risk & Accessibility
Are you aware of any access or risk issues that need to be taken into consideration when visiting this household? Risk issues may relate to this family and/ or other people who visit the home. (Drug and Alcohol, Mental Health, Domestic Violence, Gang Related Violence, Pets etc)
Have you attached your own risk assessment? Yes o No o Pending o Not known o
5. Other Service involved (Consent to contact other agencies Yes o No o)
Name of worker / Organisation / Telephone / Email Address
6. Referrers Details
Contact Name:
Telephone No: / Email:
Organisation Name:
Relationship to client:
7. Client consent
Has the family consented to this referral? Yes o No o
Client Signature………………...... Print Name……………………………. Date……………………….
Please return the completed form to Via EMAIL OR FAX :
Shelter, Colonial Chambers, 3-11 Temple Street, Liverpool L2 5RHEmail: / Tel: 0344 515 1900
Fax: 0344 515 2912