Trailblazer referral form
Please complete as much as possible. Send to
Applicant details:
Name:Date of Birth:
Contact Number:
Email:
Address (including postcode):
Accommodation type (Private/Social tenancy, homeowner, hostel, etc):
Landlord /housing provider name and details (if known):
Date moved in (if known):
Referrer’s details:
Organisation:Name and job title:
Contact details:
Referral date:
Support agencies currently involved (if known):
Other household members (if applicable):
Name: / Name: / Name:DOB: / DOB: / DOB:
Relationship to main applicant: / Relationship to main applicant: / Relationship to main applicant:
Address (including postcode): / Address (including postcode): / Address (including postcode):
Contact number: / Contact number: / Contact number:
Name: / Name: / Name:
DOB: / DOB: / DOB:
Relationship to main applicant: / Relationship to main applicant: / Relationship to main applicant:
Address (including postcode) / Address (including postcode): / Address (including postcode):
Contact number: / Contact number: / Contact number:
Nationality:
Actual nationality of main applicant:Residential status of main applicant (UK resident):
Employment status of main applicant:
Benefits status of main applicant (eg Housing Benefit claim):
Rough sleeper details:
Has main applicant ever slept rough?How many nights slept rough in past year?
What age when first slept rough?
Previous homelessness:
Has main applicant ever been homeless before?When was applicant first homeless?
What age when first homeless?
How many addresses held in past 2 years?
Has main applicant been temporarily accommodated by any Local Authority in past 5 years?
Prison:
Has main applicant been in prison in last year?Date main applicant left Prison?
Was main applicant homeless prior to Prison?
Did main applicant receive resettlement advice in prison?
Housing situation:
Please explain in as much detail as possible what the applicant’s current housing circumstance is.Are there any rent arrears at their current or previous property? Etc..