Making A Housing Referral - Community Support CIC

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Referral Form: Supported Housing

To best understand the housing needs of the applicant, and to conclude if we can offer accommodation, please ensure that all questions are answered, and that any supporting documentation is made available. Without this information we will be unable to offer accommodation or complete an application. The application form must be signed or verified by a local authority professional from the department making a referral.

Section A

Applicant Personal and Contact Details

1. Name of proposed tenant*

2. Date of birth*

DD slash MM slash YYYY

3. National Insurance Number*

4. Gender*

Male

Female

Other

Prefer not to say

5. Last previous address resided in*

6. What was the type of accommodation?*

7. Referrer name*

8. Referrer contact number*

9. Referrer Email*

10. Relationship to applicant*

Section B

Housing Requirements

1. Any risk of homelessness?*

Yes

If YES, by when?*

DD slash MM slash YYYY

2. Desired accommodation location?*

3. Can applicant live with others?*

Yes, only with males

Yes, only with females

Yes, with males or females

4. Any specific accommodation needs?*

Wheelchair accessible

A bedroom for overnight staff

Level access

Detached accommodation

5. Any further essential requirements?*

(e.g. access to public transport, specific amenity, garden space, ground floor bathroom, wet room)

Note: The greater number of essential requirements, the more time you may have to wait for accommodation to be sourced or become available.

Section C

Support Requirements

1. Any diagnosed conditions?*

Yes

2. If YES, please state the diagnosis*

3. Can the applicant read and/or write?*

Yes

4. Is info required in a specific format?*

Please state format required:

5. Is overnight care required?*

Yes

6. If YES, please state requirements*

Sleeping staff

Waking night staff

I don't Know yet

7. Name of care funding local authority*

8. Social worker contact details*

Name*

Tel*

Email*

9. Is any specific help required with any of the following?*

Applying for Welfare Benefits

Keeping their home safe

Paying for utility bills

Paying for TV license

Cooking

Making a complaint

Keeping their home clean

Understand tenancy contract

Reporting maintenance faults

Getting on with co-tenants

Carrying out weekly shopping

Managing their money

Arranging contents insurance

Maintaining their garden

10. Is there any history of tenancy issues that may affect the applicant’s ability to adhere to the terms of the tenancy agreement?*

Issues may be:

Non-payment of rent,
Noise complaints,
Anti-social behaviour
Damage

11. State any criminal convictions*

Schedule 2, Part II of the Housing Act 1988 reads: ‘Grounds on which Court may Order Possession… …17. The tenant is the person, or one of the persons, to whom the tenancy was granted, and the landlord was induced to grant the tenancy by a false statement made knowingly or recklessly by - (a) the tenant, or (b) a person acting at the tenant’s instigation

Section D

Mental Capacity

1. Does the tenant have sufficient mental capacity to enter into a tenancy agreement?*

Yes

DOCUMENT REQUIRED: Mental Capacity Assessment*

Max. file size: 50 MB.

Note: if a tenant lacks capacity to enter into the agreement, it can only otherwise be signed by a power of attorney or deputy appointed by the Court of Protection. To comply with the Mental Capacity Act 2006 and the guidelines issued by the Court of Protection, you will need to provide proof of the deputyship order issued by the Court of Protection. If an order can’t be provided or the tenant has been assessed as lacking capacity to sign the agreement, but a deputy hasn’t been appointed, a license may be issued prior to the order being received

2. If the tenant lacks capacity, who will be signing the tenancy agreement?*

Court Appointed Deputy

Court Appointed Power of Attorney

DOCUMENT REQUIRED: Order from the Court of Protection*

Max. file size: 50 MB.

3. Please provide their contact details*

Name*

Tel*

Email*

4. Who is responsible for managing the tenant’s finances?*

Tenant

Local

Support Provider

Court Appointed Deputy

Court Appointed Power of Attorney

Other

5. Provide the contact details of any organisation or person who manages the prospective tenant’s money*

Name*

Tel*

Email*

6. Is the prospective tenant classed as ‘Severely Mentally impaired’, for the purposes of Council Tax?*

Note: For Council Tax purposes a person is considered as being severely mentally impaired if he or she has a severe impairment of intelligence and social functioning, however caused, which appears to be permanent.

Yes

Section E

Income and Benefits

1. Is the tenant in receipt of the following welfare benefits?*

Disability Living Allowance (DLA) Care

£ Per Week

Awarded

Disability Living Allowance (DLA) Mobility

£ Per Week

Awarded

Personal Independence Payment (PIP)

£ Per Week

Awarded

Employment and Support Allowance (ESA)

£ Per Week

Awarded

Income Support

£ Per Week

Awarded

Severe Disability Premium (SDP)

£ Per Week

Awarded

Universal Credit

£ Per Week

Awarded

Note: If the tenant is not presently in receipt of these benefits, they may be able to claim them if they are moving from family care, school, hospital or a residential service. Although we can provide support with benefits; we cannot apply for these on behalf of our tenants or take any responsibility for non-payment of rent if Housing Benefit will not pay the rent in full.

2. If the tenant is in receipt of DLA care component, please state which rate:

Lower rate

Middle Rate

Higher Rate

3. Please state any other benefits received, have been applied for, or you are waiting to hear about

4. Approximately how much capital, savings or investments does the applicant have?*

This includes bank accounts, savings, shares, property.

5. Please provide any other relevant financial information here

6. Does the applicant receive any income other than from Welfare Benefits?*

Yes

7. If YES, please provide details of the nature and amount of these payments*

(e.g. from working, a pension or other)

Type of Income

£ Per Week

Type of Income

£ Per Week

Type of Income

£ Per Week

8. Does the applicant currently claim Housing Benefit?*

Yes

9. If YES, what is the claim reference number*

10. Which local authority has awarded Housing Benefit?*

Section F

Consent to Discuss Application & Share Information

1. Are you happy to share the following information/documents with us, or authorise the relevant bodies to do so?*

Welfare Benefit award notifications (from DWP)*

Yes

Support Plan (by Social Worker or Support Provider)*

Yes

Housing Benefit Application Information (from HB office)*

Yes

Placement Agreement (from Social Services or Support Provider)*

Yes

Confirmation of diagnoses (from Doctor/Medical Staff)*

Yes

Note: This will assist CS CIC to ensure that the tenant is claiming the correct benefits, exemptions and rate of Housing Benefit. If you grant consent to share this information but cannot provide it, we will speak to the holders of this information (such as DWP, Social Services, Housing Benefit etc.) to obtain a copy

Section G

Other Relevant Information

1. Please use this section to provide any further information that you feel may be relevant

Section H

Signatures & Declaration

I understand and agree with the following:

CS CIC will use this information to determine whether it can offer supported housing to the person being referred.
CS CIC may use any information provided on this form in connection with this.
CS CIC and the nominated care provider will share information relating to any tenancy issued, including the rent accountand any matters that may constitute a breach of tenancy.
If inaccurate or incomplete information is provided and a tenancy is issued, any housing benefit award may be restricted below the level of the rent and the tenant will be required to contribute to the rent from their other income or savings.

Signature:*

Max. file size: 50 MB.

(Take a picture of your Signature & Upload here)

Name:*

Date

DD slash MM slash YYYY

Relationship to Applicant:*

Section I

Optional Data Collection

If you wish to state the tenant’s ethnicity, please do so here

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