About this form
Use this form to refer someone:
- if you think they are at risk of homelessness
- they are homeless or sleeping rough
To complete this form you will need:
- details of your public authority, including your authority’s name and address
- your contact details
- the referred person’s name, date of birth and contact details
- the referred person’s National Insurance number
- details of the referred person’s housing history for the last 6 years, including any periods of rough sleeping
- details of any medical, mental health or accessibility needs
- details of any sources of income
- details of any other people effected by the referral including:
- spouse or partners
- dependent children - under 18 years old
- non-dependant children - over 18 years old
- Proof that consent has been given for your authority to refer the person