Basis @ 336
Resource Centre
336 High Street
Gateshead
NE8 1EN

Oasis Aquila Housing Bond Scheme - Referral Form

Please complete this form and send to the address overleaf. The Oasis Aquila Housing Bond Scheme will contact your client directly to arrange an assessment appointment as soon as possible.
Please note that we cannot guarantee that all referrals will be accepted onto the scheme or that we will be able to find suitable accommodation for successful applicants.
To discuss your referral please call 0191 499 8020 to speak with project staff.

Section A – Client details
First name
Last name
Date of Birth / Age:
National Insurance No.
Current address or contact address
Contact Telephone No.
E-mail address
Gender / Female / Male
Ethnic origin (tick one)
White - British or Irish / Black - Other / Asian - Other
White - Other / Asian – Indian / Chinese
Black - Caribbean / Asian – Pakistani / Mixed
Black – African / Asian - Bangladeshi / Other (please specify)......
Does your client consider them self to have a disability, long term illness, physical or mental health condition? Yes No
Current housing situation (tick one)
B & B or other temporary / Night shelter / Staying with friends
Children’s home / Owner occupier / Staying with parents
Foster care / Prison / Staying with relatives
Hostel / Private rented / Supported accommodation
Local Authority accommodation / Rough sleeper / Other (please specify)
Housing Association accommodation / Squatting
How much rent is currently being paid? / £
Date by which client must leave current accommodation?
Principal reason for homelessness or threat of homelessness? (tick one)
Asked to leave / Harassment from landlord / Relationship breakdown (separation)
Asylum seeker / Harassment from neighbours / Relationship breakdown (parents)
Disrepair / Left by choice / Rough sleeping
Eviction tenancy / Leaving care / Unsuitable accommodation
Eviction hostel / other temporary / Landlord sold property / Violence at home
Mortgage repossession / Property too expensive / Other (please specify)
Section B – Tenancy Sustainment and Independent Living Skills
Are there any key risk factors that may lead to your client losing their tenancy? (e.g.mental or physical health problems, substance misuse, arrears, offending, budgeting, form filling etc)
Please give details of support that has been given to the client around these risks in order to prepare them for moving and support that will be available during and after the move?
Have you as the referrer observed any of the following needs/problems?
Welfare benefits / Alcohol / Cooking
Debt/money advice / Life skills / Personal care advice
Mental health / Training/employment / Housing advice/accommodation
Drugs / Loneliness / Other (please specify
Where did you hear about Oasis Aquila Housing Bond Scheme?
Section C - Referral Agency Contact Details
Name of worker: / Job Title:
Organisation and contact address:
E-mail address:
Date of referral: / Telephone:

Please advise your client(s) to bring proof of their ID, current income and contacts for two referees to their appointment with us as this will greatly improve the prospects of us being able to assist them quickly.

Office use only
Date Received:

Please complete above details as fully as possible and send to:

Oasis Aquila Housing Bond Scheme, 336, High Street, Gateshead, NE8 1EN or,
Fax: 0191 491 1830 or,
E-mail: