Please Note:

This form is to be completed by Care Providers only

Form to Be Completed & Submitted to Trinity Housing at least 2 Weeks before Moving in a Tenant

Before the Service User moves into Trinity Housing accommodation, the application needs to be approved by Trinity Housing, for any emergency moves, please contact Trinity Housing beforehand

All fields are mandatory

1. REQUESTER DETAILS

Your Full Name

Name of Organisation

Your Email

Telephone Number

Position/Job Role

2. SERVICE USER DETAILS

Title

Surname

First Name

Sex

DoB

Service User Email Address

Service User Telephone

National Insurance Number

Proposed Tenancy Start Date

Property Address Moving To

Do you have capacity to sign a tenancy agreement

Does the person looking for housing have a learning disability?

3. PREVIOUS TENURE – If this info is not provided it will delay the referral decision

Previous Address (include full address & post code)

Previous Landlord Details (include full name, address & post code)

Was this a supported tenancy

Do you have any rent arrears from your previous tenancy?

Did you receive Housing Benefit at the previous address?

Is the person able or willing to share a property?

What are the timescale for the person to move?

Does the person have paid support in place?

Is sleep in support required?

Do you have a Community Care Assessment or Independent Assessment?

Please give details how this care, support or supervision will be funded?

Are there any warning signs that usually precede risk issues / triggers?

Do you have a criminal record?

Do you have a history of Substance Misuse?

Do you have any history of Arson?

Do you have any history of Challenging Behaviour?

Do you have a history of any Anti-Social Behaviour?

Do you have a history of any of the following (select all that apply)?

Declaration
I confirm that the information provided in this referral form, and in any supporting documents submitted with it, is true, accurate and complete to the best of my knowledge and belief at the time of submission.
I understand that Trinity Housing Association will rely on the information provided to assess the referral and make decisions regarding suitability and eligibility. I also understand that the provision of false, misleading or incomplete information, or the omission of relevant information, may result in the referral being delayed, rejected, withdrawn or, where applicable, treated as a potentially fraudulent referral.
By submitting this form, I confirm that I am authorised to make this referral and to share the information and documentation provided.

I have read and agree to the declaration above.

tick here to agree