Client Referral Form

NOMAD SmartRenting Scheme- 21-35 year olds Application Form Name of Applicant: ………………………………………………………………………. Date of Application :………………………………………………. Age: Single Yes/ No Couple Yes/ No Do you have any children living with you? Yes/ No Are you presently homeless? Yes/No Have you ever experienced homelessness before? Yes/No Are you in priority need? Yes/ No Do you have a letter confirming this decision? Yes/ No

Referring Agency:

Flow/ Returner?

Referral Yes/ No Criteria met Yes/ No Assessment Yes/ No Logged booked

1 Section A – Person

Print Name: …………………………………………………………………………………….. Date of birth: Date: ……… Month ……… Year………….. Age: ……………..

NI number: ……………………………………………………………………………………..

Contact Address: ………………………………………………………………………………..

Postcode: ……………………………………………………………………….

Is this a c/o address (friend/family/agency?) Yes No

If YES please give details………………………………………………………. Phone………………………………………………… Mobile……………………………………… Is it OK to leave message at this address/telephone number? Yes No

Next of kin: …………………………………………………………………………………………………

Relationship to you: ……………………………………………………………………………………….. Contact Address:…………………………………………………………………………………………… Telephone number: ………………………………………………………………………………………

Did anyone refer you here? (Tick one)

Alcohol agency Housing dept SS (young people) CPN / mental health team SS Probation Other Voluntary sector Other: …………………………. Drugs Agency Self

2 Section B – Equal Opportunities Monitoring

How do you describe your ethnic origin? (Tick one)

White English Black – Caribbean Mixed – White & Black African White Welsh Other black background Mixed – White & Black Caribbean White Scottish Asian – Pakistani Mixed – White & Black British White Irish Asian – Bangladeshi Mixed – White & Asian Other white background Asian – British Chinese Black – British Asian – Indian Did not answer Black – African Other Asian background Other ………………………….

How would you describe your current status? (Tick one)

Single male Single parent male Couple w/out children (male) Single female Single parent female Couple w/out children (female) Family (female) Family (male) Same sex couple w/out children (female) Same sex couple w/out children (male) If there are children, please state how many?......

Do you have access to children?......

Section C – Housing Situation

What is your current housing situation? (Tick one)

B & B or other temporary accommodation Private rented Children’s home Rough sleeper Foster care RSL Hostel Squatting Local Authority accommodation Staying with friends Mobile home Staying with parents NFA / sofa surfer Staying with relatives Night shelter Supported accommodation (long term) Owner occupier Tied accommodation Prison Other (please specify)……………………………

What is the principal reason for you being homeless or vulnerable to homelessness? (Tick one)

Asked to leave Landlord sold property Armed forces Leaving prison Asylum seeker Mortgage repossession Bereavement End of shorthold (NTQ)

3 Disrepair Property too expensive Eviction tenancy – arrears Relationship breakdown (separation) Eviction tenancy – anti-social behaviour Relationship breakdown (parents) Eviction hostel / temporary accommodation Relapsed from dry house Hospital discharge Rough sleeping Harassment from landlord Unsuitable accommodation Harassment from neighbours Violence at home (domestic) Left by choice Violence at home (racial / other) Leaving care Other (please specify)………………………………

Have you ever slept rough? Yes No

When was the last time you slept rough? Day ………. Month ……… Year ……….

Overall how long have you slept rough for? (Tick one)

Less than 1 week 6 – 12 months Over 10 years 1 week – 1 month 1 – 2 years Never 1 – 3 months 2 – 5 years Did not want to answer 3 – 6 months 5 – 10 years

Where did you stay last night? (Tick one)

Family home NFA Prison Hostels / B&B temp Night shelter Rough sleeping Friends / relatives / partner Own home Squatting Other institution (please specify)…………………………

Do you have a Homeless case? Yes No

Do you have priority with the Homeless section? Yes No

Details of outcomes with Homeless Section: ……………………………………………………………………….

………………………………………………………………………………………………………………………………......

4 Section D – Additional Support

Do you consider yourself to have a disability? Yes No

Are you registered disabled? Yes No

Are you currently taking any medication? Yes No

Give details of current / past health problems. (E.g. epilepsy, diabetics, high blood pressure)

......

Have you had any mental health problems? Yes No

If yes, give brief details of past mental health history......

......

Are you involved with any mental health services? Yes No

If yes, detail which ones (include dates and key contacts): ………………………………………………………

……………………………………………………………………………………………………………………………..…

Have you got any of the following needs/problems?

Welfare benefits Training / employment Debt / money advice Loneliness Mental health Cooking Drugs Personal care advice Alcohol Housing advice / accommodation Life skills Other (please specify)……………………………… Any further comments regarding support needs? (Give details of any other organisations involved in

Offering support)………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………

What other organisations are involved?

SS Young people Other vol. sector Probation CPN Drugs agency Other NHS Alcohol GP CPN / Mental health team Private Rented Standards

Section E – Income & Debts

5 How would you describe your current employment status? (Tick one)

Sick / disabled Unemployed Student full time Working full time Student part time Working part time Training full time Working full time – self- employed Training part time Working part time – self-employed

If you are currently employed, what is the length of your contract?......

What is your income (net of NI and tax)? £……………………per week

Are there any other deductions (e.g. attachment of earnings)? ......

Are you currently in receipt of any benefits? Yes No

If YES please tick receiving benefit and list weekly amount of award:

JSA(C) £………… JSA (IB) £………….. ESA £…………… IS £…………….

Are you claiming benefits as a couple? Yes No

Other DSS benefits eg. Child Benefit DLA ………………………………… Other sources of income eg. Maintenance………………………………… Debts Rent arrears Amount £…..… Payment arrangements ……………………………………… Water arrears Amount £…..… Payment arrangements...... CTax arrears Amount £…..… Payment arrangements...... Gas arrears Amount £…..… Payment arrangements...... Electric arrears Amount £…..… Payment arrangements ...... Credit/store cards Amount £…..… Payment arrangements...... Overdraft Amount £…..… Payment arrangements...... Social fund Amount £…..… Payment arrangements...... Court fines Amount £...…… Payment arrangements......

Are your financial circumstances about to change? Yes No If so, how? …………………………………………………………………………………………………………………… ......

......

6 Section F – Legal

Have you ever served time in Prison? Yes No If yes, give details: …………………………………………………………………………………………………………......

Do you have a probation officer/named worker? ...... Yes No

Name: ……………...…………………………………………………………………………………………………………. Contact Tel: …...……………………………………………………………………………………………………………..

Give Details: ………………………………………………………………………………………………………………..

Section G – Housing Preferences

Which areas would you consider? (Give details)

Which areas would you NOT consider?......

Do you have any children and if so how many? …………………

Is there regular access to any children? Yes No

If so, does this affect your accommodation needs? (Give details)

......

Are there any other factors which may affect the suitability or otherwise of a property (i.e. pets, mobility)?

......

7 Section H – Other people to be housed with Applicant

Partner

Name......

Gender…………… Age……………

Person one Name......

Gender…………… Age……………

Relationship to main applicant......

Section I – Evidence for Housing Benefit

(Please state what forms of evidence has been viewed)

Identity (e.g. medical card, birth certificate, driving licence): …………………………………………….…………...

National Insurance Number (e.g. DWP letter, NINO card, payslip): ……………………………………………….

Do you have a bank account? Yes No

Evidence of Bank Account (e.g. bank statement): ……………………………………………………………………

Is this a joint account? Yes No

If so, state name of joint account holder and relationship to applicant: …………………......

………………………………………………………………………………………………………………………………..

8 Section J – Sustaining a Tenancy

Does this client require low level Resettlement Support? Yes No

Does this client require medium / high level Resettlement Support? Yes No

Please give reasons for your answer:.…………………………………….. …………………......

………………………………………………………………………………………………………………………………..

Will this client require direct payments to landlord? Yes No

If yes, please provide reasons why: …………………………………….. …………………......

………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………

Referrers Signature …..

Applicants Signature

PLEASE RETURN THIS FORM TO:

Nomad, 12-14 Burngreave Road, Sheffield, S3 9DD, telephone 01142412080, fax 01142787468