Referring agency details
Are you a public body with a duty to refer? *
Type of public body
Please select
Adult secure estate (prison)
Youth secure estate
National Probation Service
Community Rehabilitation Company
Police
Hospital (A&E or in-patient)
Mental health service - acute in-patient
Mental health service - community based
CAMHS
Sexual health services
Community health visitors
Community midwives
GPs
Substance misuse treatment service
Adult social services
Children's social care
Children's early help services / children's centres
Troubled families / families intervention programme
Youth services
School
Further Education college
University
DWP - Job Centre Plus
Housing Benefit / Welfare Assistance Service
Citizens' Advice / Debt Advice Agency
Private Registered Provider (housing association)
Local Authority Landlord
Private Landlord
Supported Housing Provider
Housing First Provider
Refuge Provider
NASS accommodation provider
Armed Forces / Veteran Support Service
Environmental health
Community Safety
Nil Recourse team
Other Local Authority service
Street service for rough sleepers
Housing related (floating) support provider
Other service provider (not housing related)
LGBT+ support agency
Faith organisation
Name of your organisation *
Is your client aged 16 or 17? *
Your post or role *
Your name *
Your email *
Your phone number *
Person being referred details
Your client's first name *
Your client's surname *
Your client's date of birth *
Your client's gender *
Please select
Male
Female
Your client's nationality *
Your client's address *
Your client's postcode *
Your client's National Insurance number *
Is your client currently homeless? *
When will your client be without accommodation? *
Please select
Today
Within 7 days
8-28 days
29-56 days
57-90 days
91 days or more
Does your client live in the City of Wolverhampton? *
State why you are referring this client *
Does your client have somewhere safe to stay tonight? *
Has your client been referred by social services to apply for housing as part of their assessment process? *
Has your client given you consent to refer them to us? *
Your client's preferred contact method *
Please select
Call to mobile
Text to mobile
Email
Landline
Other
Your client's phone number/s
Your client's email address
Do you agree to help your client with initial contact to help their housing application or assessment, if required? *
Has your client been referred elsewhere? *
Does your client want us to contact any other person as part of their referral to us? *
Client support needs
Is your client's safety at risk? *
Is your client leaving one of these types of accommodation? *
Please select
Care services (eg children's home or foster care)
Prison
Probation hostel
Armed forces accommodation
Hospital
Residential care
Not applicable
Other
Is your client is experiencing the following situations? *
Give details of any relevant medical, health issue or special/support needs of your client *
How many people are in the household that you’re referring to us (including the applicant)?
Number of adults *
Number of children *
Consent
I / we confirm that we are referring the person / household to the City of Wolverhampton as we believe they are at risk of homelessness and confirm they have given their consent to this referral. *
