HOUSING OUTREACH TEAM

Referral

Section 1. Applicant Information

Applicant Name: DOB: Age

NI Number: Rent Account Number: Marital status

Gender: Male  Female 

Ethnic Origin:

White British  White Irish  White Other  Mixed Black & White Caribbean 

Mixed Black and White African  Mixed White and Asian  Mixed Other 

Asian-Indian  Asian Pakistani  Asian Bangladeshi  Asian Other 

Black Caribbean  Black African  Black Other  Chinese 

Gypsy/Traveller  Other  Declined to answer 

Sexuality: Heterosexual  Gay  Bi-sexual  Transgender  Declined to answer 

Address:

Post code Tel. No Mobile.

Email

Can we contact you at the above address Yes No 

If No please provide a correspondence address Old address awaiting new address after swap of properties confirmed.

Tenure: Council Tenancy  Private Rented  Housing Association Tenancy

Temporary Accommodation (e.g. hostel or foyer)  No Fixed Abode 

Household details – who is living with you

Name / DOB / Relationship to Applicant

Section 2. Referral information

Maintaining accommodation/Avoiding eviction / Obtaining paid work/Work like Activities
Training/Education
Reducing Debt/ Rent Arrears Amount ETC.
Contact with external/groups/friends/family
Better manage physical health/Mental Health / Assistive technology/aids & adaptations
Better manage substance misuse / Other, setting up new home furnishing etc.

Is applicant aware that the referral has been made Yes  No 

Is anyone else supporting the applicant Yes  No  Don’t Know 

If yes please state below:

Agency / Name and contact details
Carer
GP.
YOT worker
Mental health professional
Social worker
Support or Key worker
Probation Officer
Other

Signature: (applicant)

Date:

Risk Assessment

(Referring officers must complete to the best of their knowledge)

Accommodation & Tenancies (Please circle yes or no)
Do you currently have your own tenancy? / Yes / No
Have you ever been evicted, asked to leave or abandoned a property? / Yes / No
Do you owe any rent arrears on any property you have lived in? / Yes / No
Offending History (Please circle yes or no)
Have you ever been:
Cautioned/arrested/prosecuted/imprisoned For any violent or sexual offence? / Yes / No
If yes please provide further details below:
Health Issues (Please circle yes or no)
Do you have any Physical or Mental health issues? / Yes / No
If yes please provide further details below:
Drug or Alcohol Issues (Please circle yes or no)
Does applicant have an alcohol or drugs problem? / Yes / No
If yes please provide further details below:
Any other Risks (Please circle yes or no)
Are you aware of any other risks in relation to the applicant or their property? / Yes / No
If yes please provide further details below:

RISK ASSESSMENT SUMMARY

Summary of Risk / Level of Risk
(Please circle which applies)
Risk to Self / LOW MEDIUM HIGH
Risk to other professionals / LOW MEDIUM HIGH
Risk to members of the public / LOW MEDIUM HIGH
Risk to vulnerable Adult/Child / LOW MEDIUM HIGH

REFERRAL/ASSESSMENT COMPLETED BY:

Name: Tel No:

Organization:

Position held:

Signed: Date:

Guidance for referrers

The Housing Outreach Team can help prevent eviction. We offer practical help with rent arrears, benefits, private renting issues, debts, accessing other services and advice across a wide range of housing related issues.

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2014 Civic Centre, St Peter’s Square, Wolverhampton, WV1 1RT 01902 551023