Housing Support Self-referral Form

This form can be completed by the tenant or leaseholder, or on their behalf by someone else.
We will write to you within 5 working days of receiving your completed form.
This service is available to Homes for Islington tenants and leaseholders only.

1. Applicant Details
Full name
National Ins. No
HB Ref. (if applicable)
Rent Account No.
Address
Post Code
Telephone number(s)
Email address
Date of Birth		Male	Female
The applicant is an:	Islington tenant	Islington leaseholder

2. Who else lives in the household?
Surname	First name(s)	Gender	Date of birth	Relationship to applicant
1.
2.
3.
4.
5.

3. Who is making the referral?		Myself Someone else
If you are making a referral for yourself, go straight to section 4 If you are referring someone, please complete this section in full
Referee’s name
Referee’s organisation (if applicable)
Referee’s address
Referee’s email address
Referee’s telephone number(s)
Does this person know that you are making this referral?	Yes	No
Have they agreed to a referral?	Yes	No

4. What support needs does the applicant have? (Tick all that apply)

Domestic Abuse / Violent Relationship

Homeless or threatened with homelessness

Learning Difficulties

Chronic Illness

Mental Health Issues

Vulnerable Lone Parent Family

Alcohol Dependency

Vulnerable Two Parent Family

Drug Dependency

Elderly Person

Physical Disability

People with Sensory Impairment

Young and Vulnerable

HIV and AIDS

Threat of eviction due to rent arrears

Threat of eviction due to anti-social behaviour

Any other needs (please specify)

5. What kinds of housing support are required? (Tick all that apply)

Help to liase with other agencies

Help filling in forms

Help claiming welfare benefits

Help resolving conflicts with friends, neighbours or family members

Help accessing training and education

Help accessing community groups and other local services

Referral to other specialist support services

Help with furnishing or adapting your home

Advice on managing your money and help with budgeting

Help keeping clean and safe within your home

Advice and help with parenting and childcare

Don’t know

Any other support (please specify)

6. Please give details of the support you need

7. Risk Assessment (Tick all that apply)

Do you or have you had any of the following?

Yes No

Domestic Violence

Violence towards staff/support agencies

Violence towards family

Violence involving weapons

Violence involving alcohol/drugs

Violence involving racist orientations

Violence involving fire/arson

Other

If yes (please specify)

8. Are any other support agencies involved?

Social worker

Occupational therapist

Home Care

District Nurse

Any other support agency (please specify)

Please provide contact details for any agencies involved:
Name
Organisation
Address
Telephone number(s)
Email address

9. Ethnic origin of applicant
Asian or Asian British	Indian Bangladeshi Pakistani Any other Asian background (please state)
Black or Black British	Caribbean Somali Eritrean Nigerian Ghanaian Any other African background (please state) Any other Black background (please state)
Chinese or other ethnic background	Chinese Filipino Vietnamese Any other ethnic background (please state)
Mixed	White and Black Caribbean White and Black African White and Asian Any other Mixed background (please state)
White	British Greek / Greek Cypriot Irish Kurdish Turkish / Turkish Cypriot Other White background (please state)

10. Contacting the applicant
What is the applicant’s first language?	Albanian Arabic Bengali British Sign Language Cantonese English Greek Portuguese Somali Spanish Turkish Other (please state)
Does the applicant need an interpreter?	Yes	No
Are there any other communication needs?	Signer Reader Other (please state)

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Housing Support Self-referral Form