Strictly Private and Confidential

6 Laundry Close, Thorpe St Andrew, Norwich. NR7 0XHTel: 01603 435449.

e-mail: website:

HOUSING REFERRAL

All sections of this referral form MUST be completed fullyto enable the application for accommodation with The House of Genesis to be properly considered.When answering “Yes” to a specific question, it is important to provide full details; likewise the applicant must sign The Statement and Informed Consent section at the end of the form.

Once completed please return to the above address or email preferably along with a copy of a recent HAF form and/or risk assessment.

THE REFERRER/THE AGENCY
Name
Agency
Address / Job Title
Telephone
Fax
Email
DETAILS OF APPLICANT
Full Name
Current Address / Telephone Contact
Date of birth
(must be at least 20)
Marital Status
N.I. Number
Current Housing Status (Delete as Applicable)
  • Street homeless
  • Staying with family/friends
  • Hostel
  • B&B
  • In Custody
  • Other –Please Specify
How long has the applicant been in their current housing situation?
Earliest Date Accommodation Required
Details of Dependents (including Partner and/or children)
Access/Visiting arrangements
Does the applicant have any family or close friends living in the Norwich area?

HEALTH & WELLBEING

Please indicate if any of the following have previously or currently apply to the applicant and give details:

Serious accident / mental illness / disability / mental health problems / self harm /

treatment for drink or drug addiction / infectious diseases.

Any current treatment for any medical condition or taking any prescribed medication?

Any current special dietary requirements?

OFFENDING HISTORY
Please Provide a Summary of Offences
Date and Details of Last Conviction
Are there any court cases pending?
Is the applicant on any of the following: Licence, probation,Conditions of Residence, Bail, Electronic tagging, Curfew or Community Service?
Name and Address of Probation Officer (if appropriate)
Does the applicant have convictions for any of the following types of offence?
Arson
Drink or Drugs
Offences Against Children
Sexual Offences
Violence / Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
If yes, please givefull details; however please note that the admission of such offences would not necessarily invalidate an application. Each application will be judged entirely on its merits.
FINANCIAL SITUATION
What benefits or other income is the applicant receiving?
What level of debts/arrears does the applicant have?
Are there any fines imposed by a court?
Are there outstanding loans from DSS – if so how much?
Is the applicant required to pay maintenance for a child/children?
ANY ADDITIONAL RELEVANT INFORMATION?Please include details of other known agencies working with the applicant
APPLICANT’S STATEMENT & INFORMED CONSENT TO SHARE INFORMATION
The information contained in this form is true to the best of my knowledge and belief. I give my consent for the above named referring agency to openly discuss my situation and circumstances with The House of Genesis, as may be reasonably required to enable them to assess my housing application. I understand that this information will be kept strictly confidential and not discussed with a third party.
Signed Date

1

The House of Genesis