1Referrer details 2Referral details 3Main applicant details 4Employment 5Health, Disability and Special Needs 6Nationality and family information 7Eviction notice and rent arrears details 8Evidence to be provided with your application 9Summary Progress Details of the person requesting referral Before you proceed do you have the permission of the applicant to submit this information on their behalf? Yes No Sorry, you cannot continue with this form without their permission. What is your role? I am a partner agency making a referral I am making a referral on behalf of a friend/family member Referral on behalf of friend/family member Role of person referring Name of person referring Address of referrer Email address of referrer Phone number of referrer Partner agency making a referral Please indicate which agency is referring the main applicant -- Please Select -- Probation Service Armed forces / Veteran Support Service GP Adult Social Care DWP Charity Support Service Childrens Social Care Childrens Early Help Services Citizens Advice Bureau Community Safety Hospitals/A&E Homeless & Housing Support Service LGBT Support Agency NASS Accommodation Provider Police Private registered Provider (Housing Association) School, Youth & Education Provider Street Service for Rough sleepers Street Link Refugee Support Service Other If Other, please specify Probation Service Please can you provide the following information for the customer you are supporting. Release date / Homelessness date (dd/mm/yyyy) Current Prison or approved premises Details of most recent conviction Date of sentence (dd/mm/yyyy) Sentence received Historic conviction details, if any ( please include any arson or sexual offences) Summary of identified risks and the impact on housing placement Does the customer have a history of substance misuse? Yes No Please provide details of customers substance misuse and any treatment the customer is currently receiving Is there any additional information that you think we should be aware of? (optional) Agency referral details Name of organisation referring If you are not an agency, please type none Role of person referring Name of person referring Business address of referrer Email address of referrer Telephone number of referrer Name and contact details of any other person who could be contacted for further information Urgency of case Immediate action required Action needed within the next 7 days Action needed within the next 28 days No information is required, please proceed to the next page. Referral information Please select any circumstances that apply to them or their household from the list below. If none apply, choose 'They do not meet any of this criteria.' You may be expected to provide evidence for the criteria you choose Fleeing Domestic Abuse or fear of Domestic Abuse Fleeing fire or flood or other disaster They or their partner or somebody in their household is pregnant They have dependent children who reside with them They are 16 or 17 and not looked after by social services They are 18, 19 or 20 years old and have spent time in care between the ages of 16-18 They are over the age of 65 They are disabled They are vulnerable as a result of mental illness or physical health condition They do not meet any of this criteria If they are fleeing domestic abuse or fear of domestic abuse, we will need to see evidence to support this claim, such as a crime reference number or police report, please have it to hand to upload at the end of this form. If you do not have any evidence you can still complete this form. If they are fleeing flood or fire we will need to see evidence to support this claim, such as an emergency services report or insurance documents. please have it to hand to upload at the end of this form. If you do not have any evidence you can still complete this form. Do they have a safe place to stay tonight? Yes No If you are making this referral between Monday – Friday 9am – 4:30pm please continue to complete this form and a member of our Housing Options Service will be in contact with you urgently. You do not need to call us. If you have not been contacted by 5pm and they have nowhere to stay please call 0151 233 3044 or freephone 0800 731 6844. If you are making this referral outside the hours of Monday – Friday 8am – 4:30pm please do not continue with this referral. Please call 0151 233 4044 immediately. If you do not call this number no action will be taken. We will only be able to place them in emergency accommodation if they meet strict priority need criteria. Please consider all your options. No information is required, please proceed to the next page. Applicant details First name Given name Last name Family name Ethnicity -- Please Select -- English Welsh Northern Irish British Irish Bangledeshi Chinese Indian Pakistani African Caribbean Any other Black British or Caribbean background Any other Asian background Any other mixed or multiple ethnic background Gypsy or Irish Traveler Roma Prefer not to say Sexuality -- Please Select -- Heterosexual Homosexual Bisexual Prefer not to say Religion -- Please Select -- Bahai Buddhist Christian Hindu Jain Jewish Muslim Sikh None Prefer not to say Do they consider themselves to have a disability? Under the Equality Act 2010 a person is considered to have a disability if he/she has a physical or mental impairment which has a substantial and long term adverse effect on his/ her ability to carry out normal day to day activities. Yes No Date of birth (dd/mm/yyyy) Do they currently have an address? This address can be the address where they are currently residing even if they have no responsibility to pay rent (e.g. family/friend's home) Yes No Address To enter an address outside Liverpool, use the 'enter address manually' option below. Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually How long have they lived at this most recent address? It is important for us to have an understanding of their address history going back five years. Please give previous address or addresses for the last 5 years. To add another address, choose 'Add address' Address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually How many years and months did they live at this address? Add address Do they have a contact telephone number? Yes No Main contact telephone number Home telephone number (optional) (if different to above) Work telephone number (optional) Is their telephone number a smart mobile? We ask if the mobile phone number is a smart phone to establish if we can use a video call to conduct the Home Needs Assessment. If they do not have a smart phone we will telephone call them instead. Yes No If they do not have any contact number of their own please provide details of how we can get in touch with them Email address (optional) If the email address is not known, you can leave this question blank. However, please be aware that providing a valid email address supports the Housing Options service when contacting the person you are referring. National insurance number If the National Insurance number is not known you can type NK. However, please be aware that the National Insurance number must be provided to support the Housing options referral, and proof which can be found on any benefit award letter or wage slip should be uploaded on the evidence upload page at the end of this form. If this is not possible, you will have 10 days from submitting this form to provide their national insurance number. Do they have a child or children residing with them on a regular basis but who do not live with them permanently? An example of this could be their own child/ children who reside with their other parent permanently, but regularly stay with the applicant as part of an agreed arrangement Yes No Details of children To add details of another child, choose 'Add child' First name of child Given name Last name of child Family name Date of birth (dd/mm/yyyy) Relationship to applicant Please make sure you provide details of the arrangement (for example they stay with them 3 nights per week as part of a split custody arrangement) Add child No information is required, please proceed to the next page. Employment details Are they currently employed? Yes No Please select the option that describes them best -- Please Select -- Apprenticeship Full time work (30 hours a week or more) Part time work (16+ hours a week or less) Part time work (less than 16 hours per week) Government New Deal training Job Seeker Not seeking work Maternity/paternity/adoption leave Retired Full/part time student Other Please specify other What is their average weekly wage from paid employment? How many hours do they work each week? In order to support their referral please provide evidence of their employment status on the evidence page at the end of this form. This could consist of a contact of employment or a recent wage slip. Are they currently in receipt of any benefits? Please include benefits that they jointly claim with their partner. Yes No Please select any benefits that they are currently in receipt of Select all that apply. Please include benefits that they jointly claim with their partner. Universal Credit Employment Support Allowance Child Benefit Working Tax Credit Child Tax Credit Disability Living Allowance Personal Independence Payment (PIP) Other If other, please specify What is the weekly/monthly amount they receive? In order to support the referral please provide evidence of their unemployment status on the evidence page at the end of this form. This could consist of award letters, a screen shot of your Universal Credit journal or a bank statement showing Benefit payments. No information is required, please proceed to the next page. Health, Disability and Special Needs details Are they or their partner or anyone else in their household pregnant? Yes No Due date (dd/mm/yyyy) Please provide a copy of the MATB1 form or any additional medical evidence that confirms the pregnancy on the evidence upload page at the end of this form. Do they consider themselves to have any health, disability or special needs? Under the Equality Act 2010 a person is considered to have a disability if he/she has a physical or mental impairment which has a substantial and long term effect on his/ her ability to carry out normal day to day activities. Yes No Health, disability or special needs Select all that apply Audio impairment Behavioural difficulties Learning disability Mental health illness Neurological condition Other long term diagnosed illness Physical disability Poor or limited mobility Sensory condition Terminal / life threatening condition Visual impairment Wheelchair user Please provide details of their health, disability or special needs Are they currently on any medication? Yes No Please give more information Please provide the name and address of their Doctor Do they currently have a social worker? Yes No Do they qualify for Disability Living Allowance (DLA) or Personal Independence Payment (PIP) as a result of their disability? Yes No Do they have any medical specific accommodation needs? (for example, fridge required for medication, ground floor required due to limited mobility) You have stated that they consider themselves to have a health, disability or special need. In order for us to consider this as part of their assessment we will need to see evidence of this.This could consist of any of the following: Medical Reports Letter from GP Sick note Hospital Records Prescription Details Proof of DLA/PIP Please provide this on the evidence upload page at the end of this form. No information is required, please proceed to the next page. Nationality information Nationality -- Please Select -- UK National Bulgarian Croatian Czech Republic Estonian Hungarian Latvian Lithuanian Non EEA National Other EEA National Polish Romanian Slovakian Slovenian Ukrainian Are they subject to immigration control or restrictions? Yes No Do they have the right to work in the UK? Yes No Have they been granted indefinite leave to remain in the UK? Yes No You have stated that they have been granted indefinite leave to remain in the UK. As part of their assessment, we will need to see evidence of this. Please provide this on the evidence upload page at the end of this form. Proof can be immigration documents confirming positive refugee status or a passport. Family information Do they have a partner that you wish to add to this referral? Yes No What is their partner's name? What is their partner's date of birth? (dd/mm/yyyy) Are they and their partner married? Yes No Is their partner in paid employment? Yes No Please provide details of their partner's employment. Include how many hours their partner works and average weekly/monthly wage. Is their partner in receipt of any Benefits? Yes No Please provide details of their partner's benefits. Include the name of the benefit they are in receipt of, and the average weekly/monthly amount received. You have stated that their partner is in receipt of benefits. As part of the assessment, we will need to see evidence of this. Please upload this on the evidence page at the end of this form. You have stated that their partner is in paid employment. As part of the assessment, we will need to see evidence of this. Please upload this on the evidence page at the end of this form. Proof can consist of a wage slip or contact of employment. Does their partner have any support needs that we should be aware of? Yes No Please describe these support needs Do they have any children that reside with them permanently? Yes No Details of children To add details of another child, choose 'Add child' First name of child Last name of child Date of birth (dd/mm/yyyy) Does this child have any support needs that we should be aware of? Add child No information is required, please proceed to the next page. Section 21 or a Section 8 eviction notice and rent arrears details Have they been issued with a Section 21 or a Section 8 eviction notice? Yes No In order to support their assessment, you will need to provide evidence of this. Please provide a copy of your section 21 or Section 8 eviction notice and any additional letters/ notices their landlord may have issued them regarding their eviction. On the evidence upload page at the end of this form. Does it state on the letter that they have received that the Notice has been given under Section 8 or Section 21 Housing Act 1988? Yes No What date does the notice ask them to leave by? (dd/mm/yyyy) Are they up to date with their rent? Yes No How much rent arrears are they in? Have they spoken to their Landlord regarding their Section 21 / Section 8? Yes No Please add any additional information regarding their Section 21 / Section 8 you believe might be useful for us to know (optional) Are they being evicted due to rent arrears? Yes No How much are their rent arrears in total? What date do their rent arrears date back to? (dd/mm/yyyy) What is the cause of their rent arrears? -- Please Select -- Rent increase Drop in income Reduction in benefit Rent unaffordable Other If 'Other', please specify Have they tried to come to a payment arrangement with their Landlord in an attempt to clear their arrears? Yes No Please provide us with information about the arrangement Are they in receipt of Housing Benefit or the housing element of Universal Credit? Yes No Are they in receipt of a Discretionary Housing Payment (DHP)? Yes No Please add any additional information regarding their rent arrears you believe might be useful for us to know and upload evidence to support this on the upload evidence page at the end of this form. (optional) Cause of homelessness or soon to be homelessness details You will need to provide evidence of their reason for homelessness on the evidence upload page at the end of this form if evidence is available. Evidence can be in the form or formal documents or notices or can be informal letters or notes from family or friends confirming that they have asked them to leave. What is the cause of their homelessness or soon to be homelessness? -- Please Select -- Parent asked them to leave the family home Friend / Family member asked to them to leave They have been sofa surfing and can no longer continue Relationship breakdown They have been advised by the police that they cannot return to their home SERCO support has come to an end They have been sleeping rough They are fleeing domestic abuse They cannot return to their home due to fire and flood They have just got out of prison or institution and have nowhere to go They have just been discharged from hospital and have nowhere to go They have left the forces and have nowhere to go They do not have a space of safety that they can return to Other If 'Other', please specify What date will they be homeless? (dd/mm/yyyy) Do they have an active Property Pool Plus account? Yes No It is important that they are actively using their Property Pool Plus account. They can improve their chances of being re housed by placing the maximum number of bids per week and widening the geographical area they are willing to accept a property in. The Housing Options Service are able to verify the number of bids they are making, and as part of their Personal Housing Plan will request that they place the maximum number of bids each week to improve their chances of being rehoused. If they are already registered they should start actively bidding with immediate effect. The Housing Options Service may be able to use evidence that they have already provided when setting up their property pool plus account to support their Housing Needs Assessment. Do they give consent for the Housing Options Service to use evidence already provided for their Property Pool Plus account? Yes No It is important that they register for property pool as soon as possible. Once registered they should start actively bidding with immediate effect. They can improve their chances of being re-housed by placing the maximum number of bids per week and widening the geographical area they are willing to accept a property in. They can register for Property Pool online by visiting the Liverpool City Council website and typing 'property pool' into the search bar. If there is any additional information that you think we should be aware of, please provide the additional information here (optional) No information is required, please proceed to the next page. Evidence and documentation Please upload all the evidence here. If you cannot upload any of it now, you have 10 working days to send to us after you submit this form using our additional evidence upload link. We cannot book a housing needs assessment if you do not provide the evidence we need within 10 working days. To upload multiple files for a particular question, hold 'Ctrl' (Windows) or 'Cmd' (Mac) when choosing which files to upload. National insurance (optional) This can be an employment slip or benefit award letter If employed, proof of this (optional) Evidence can consist of a contract of employment or a recent wage slip. Or if unemployed, proof of this (optional) Evidence can consist of any of the following: Award letters, screen shot of your Universal Credit journal or bank statements showing Benefit payments. Evidence showing proof of homelessness (optional) Evidence can be in the form of formal documents or notices or can be informal letters or notes from family or friends confirming that they have asked them to leave. Evidence of fleeing domestic abuse (optional) This can be a crime reference number, police report or any other evidence you have that shows they are fleeing domestic abuse Evidence of fleeing fire or flooding (optional) This can be an emergency services report, insurance documents or any other type of evidence that shows they are fleeing fire or flooding Evidence of pregnancy (optional) Please provide a copy of the MATB1 form or any additional medical evidence that confirms the pregnancy Proof of health, disability or special need (optional) Proof could consist of any of the following: Medical reports, letter from GP, sick note, hospital records, prescription details or proof of DLA/PIP Evidence that they have been granted indefinite leave to remain in the UK (optional) This can be Immigration documents confirming positive refugee status or a passport. Evidence of partner's employment or unemployment status (optional) You have stated that their partner is either in paid employment or receipt of benefits. As part of the assessment we will need to see evidence of this. Proof could consist of any of the following: Wage slips, contract of employment, benefit award letters, screen shots of Universal Credit journal or Recent bank statements that show payments being made. Evidence of eviction due to Section 21 or Section 8 (optional) This should be a copy of their Section 21 or Section 8 eviction notice and any additional letters/notices their landlord may have issued them regarding their eviction. Evidence of rent arrears (optional) Please provide evidence of rent arrears and any additional letters/notices their landlord may have issued regarding their eviction as a result of rent arrears Is there any reason you cannot provide evidence with this form or within the requested 10 working days? Yes No Please give reason here Please note: If you have already told us as part of this referral that they are fleeing domestic abuse, cannot return home due to fire or flood or have nowhere to stay tonight, we will book them an emergency assessment without evidence. They may still have to provide evidence later but their assessment will not be delayed. Housing referral declaration I (we) declare that to the best of my (our) knowledge and belief the information I have given to Liverpool City Council’s housing department is correct in every detail. In submitting this application, I (we) give you my (our) permission for a doctor or other health professional to give information about me (or other), as far as the law allows. In submitting this application, I (we) give my permission for other internal departments or outside organisations to give you information so you can process my application. I (we) understand that you will copy and use this form to get the information. I fully understand that I must inform Liverpool City Council’s housing department if my circumstances change, through advising, in writing, Liverpool City Council’s housing department of any changes. If prosecuted by Liverpool City Council and found guilty I understand I could be ordered to pay a fine of up to £5,000 and/ or a term of imprisonment. Declaration Please tick this box to confirm that everyone listed in this form that is aged over 16 has read and understood the above statement No information is required, please proceed to the next page. Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page Loading form summary...