Hospital / Prison Referral

Housing Options &Advice Team

London Borough of Hackney

Hackney Service Centre

London E8 1DY

Tel: 020 8356 3000 / Fax: 020 8356 5835

Email:

Housing Referral Form

IMPORTANT

  • If submitting a written referral, please write clearly
  • Tick the appropriate boxes. If sections are not applicable to you, fill in as N/A
  • Provide supporting documentation as requested
  • Incomplete form will not be processed & will be returned to sender

DATA PROTECTION STATEMENT
The purpose of this form is to allow Hackney Council’s Housing Department to obtain from other agencies, background information necessary to start assessing applicants for suitable housing.
The information you provide will be stored in our secure council document management system and will only be shared as necessary with other housing, health and social welfare agencies or bodies as may become directly involved in their support.
REFERRING AGENCY DETAILS
Name of Agency
Name of Officer
Relationship to Applicant
Agency Postal Address (include post code)
Contact No
Email Address:
APPLICANT’S DETAILS
Name
AKA / Previous Names
Postal Address / Last Known Address (include post code)
Contact No:
Date of Birth
N.I. Number
PART ONE: Immigration Status
Indicate whether service user is subject to any known immigration control Yes No
Passport holder of:
Immigration issues:
PART TWO: Ethnicity Details
 / African /  / Irish /  / Other White European
 / African Caribbean /  / Jewish /  / Pakistani
 / Arab /  / Jewish Orthodox /  / Traveller
 / Bangladeshi /  / Kurdish /  / Turkish (Cypriot)
 / Black Other /  / Mixed White and Black Caribbean /  / Turkish (Mainland)
 / Black UK /  / Other /  / Vietnamese
 / Chinese /  / Other Mixed /  / White and Asian
 / Indian /  / Other White Background / White UK
 / Don't know /  / Don't want to say
First Language Spoken:
Interpret Required
PART THREE: Employment, Income and Benefits
Employment Status:
 / College /  / Other /  / School /  / Unemployed
 / Employed /  / Placement /  / Training Course /  / Voluntary Work
Income:
Weekly: £______ Per Annum: £______
Benefits:
 / Child Benefit /  / Housing Benefit /  / Pensioner
 / Council Tax Benefits /  / Jobseeker /  / Welfare Benefits*
*Please give details of Welfare Benefits:
______
PART FIVE: Reason for Referral (Tick the appropriate box)
Hospital Release (Go straight to Part Six)
Prison Release (Go straight to Part Seven)
PART SIX: For Applicants being released from Hospital
Reason for Hospitalisation
Date Hospitalised
Expected Date of Discharge
Other Known Conditions
Housing History for last 5 years (Start with most recent first)
Full address and postcode / Tenure*
(Landlord or Friends & Family) / Landlord name, address, postcode, contact number / Date from / Date to / Reason for leaving
Diagnosis
Applicant’s Social and Housing Needs explained
Any concerns regarding capacity to manage independent living
Risk Assessment: Risk to others
Risk Assessment: Risk to self / Self-harm
Risk Assessment: Self-neglect
Care Plan / Follow up (GP details, address, telephone no.)
Support Plan (Current treatment plan / medication)
If Yes – request a Health Questionnaire Form and submit it with this application
I have emailed over asking for this form
PART SEVEN: For Applicants being released from Prison or being referred
Reason for Conviction
Date Convicted
Expected Date of Release
Other Known Convictions
Housing History for last 5 years (Start with most recent first)
Full address and postcode / Tenure*
(Landlord or Friends & Family) / Landlord name, address, postcode, contact number / Date from / Date to / Reason for leaving
Applicant’s Social and Housing Needs explained
Any concerns regarding capacity to manage independent living
Risk Assessment: Risk to others
Risk Assessment: Risk to self / Self-harm / Drug and Alcohol use
Risk Assessment: Self-neglect
Care Plan / Follow up (GP details, address, telephone no.)
Support Plan (Current treatment plan / medication)
Is there any known medical problems?  Yes  No
If Yes – request a Health Questionnaire Form and submit with this application

Supporting Documents

To help us register your application promptly, please ensure that you include all the relevant documentation from the list below. We also advise that you do not send valuable documents by post. You can bring the original documents to your appointment at the above address whereby the documents can be photocopied and the originals documents returned to you immediately.

1. Two Proofs of Identity for each adult applicant (one of which should confirm your immigration status):

  • Passports.
  • Full Birth Certificates.
  • Immigration documents from Home Office confirming your status.
  • Full Driving Licence.
  • National Insurance card, etc.

2. Two proofs of address:

  • Tenancy Agreement.
  • Utility Bills e.g. Gas, Electricity, Water (Mobile telephone bills are excluded).
  • Proof of savings e.g. Bank/Building Society statements.
  • Wage slips with an address within the past one year, including 2 most recent monthly wage slips or 5 pay slips if paid weekly).
  • Proof of Welfare Benefits, e.g. Benefit book, Job Seeker’s Allowance or relevant documentation.
  • Letters from official bodies e.g. Schools, Hospitals, Probation, etc.
  • Other relevant documents e.g. Mortgage Statement, Marriage certificate, Notice to Quit, etc.

3. Dependent children:

  • Full Birth Certificates.
  • Custody papers.
  • Proof of Child Benefit or Family Tax Credit.
  • Proof of pregnancy, e.g. a MATBI, Hospital, or GP’s letter.
  • Evidence of schooling if appropriate, e.g. headed letter with child’s name on it.

4. EEA (European Economic Area) Nationals:

  • Home Office Registration Certificate (Accession State Worker Registration Scheme) and Wage slips within the past 12 months.

______

Please return this form to the following department to be processed:

Fax:020 8356 5835

Email:

Housing Options & Advice Team

London Borough of Hackney

Hackney Service Centre

2 Hillman Street

London E8 1DY

Tel: 0208 356 3000 / Fax: 020 8356 5835

Email: