1Referral details 2Main applicant details 3Employment 4Health, Disability and Special Needs 5Nationality and family details 6Eviction notice and rent arrears details 7Evidence to be provided with your application 8Summary Progress Referral details About your current circumstances Please select any circumstances that apply to you or your household from the list below If none apply, choose 'You 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 You, your partner or somebody in your household is pregnant You have dependent children who reside with you You are 16 or 17 and not looked after by social services You are 18, 19 or 20 years old and have spent time in care between the ages of 16-18 You are over the age of 65 You are disabled You are vulnerable as a result of mental illness or physical health condition You do not meet any of this criteria If you 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 you 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 you 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 you 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 you in emergency accommodation if you meet strict priority need criteria. Please consider all your options. No information is required, please proceed to the next page. Main applicant details 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 you consider yourself 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 you currently have an address? This can be the place you are currently staying, such as the home of family or friends, even if you are not paying rent. 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 you lived at this most recent address? We need to understand where you have been living for the past five years. Please enter your previous address or addresses for this period. 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 you live at this address? Add address Do you have a contact telephone number? Yes No Main contact telephone number Home telephone number (optional) (if different to above) Work telephone number (optional) Is your mobile a smartphone? The reason we ask this is because we can carry out assessments via video call. Don’t worry if you don’t have a smartphone, we can call you instead. Yes No If you do not have any contact number of your own please provide details of how we can get in touch with you Email address (optional) A valid email address helps us contact you, but if you don’t have one you can leave this answer blank. 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 your national insurance number. Do any children stay with you on a regular basis who don’t live with you permanently? An example of this could be your own child who regularly stays with you as part of an agreed arrangement but lives with their other parent permanently. 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 you Please make sure you provide details of the arrangement (for example they stay with me 3 nights per week as part of a split custody arrangement) Add child No information is required, please proceed to the next page. Employment Employment details Are you currently employed? Yes No Please select the option that describes you 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 your average weekly wage from paid employment? How many hours do you work each week? Are you currently in receipt of any benefits? Please include benefits that you jointly claim with your partner. Yes No Please select any benefits that you are currently in receipt of Select all that apply. Please include benefits that you jointly claim with your 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 you receive? In order to support your referral please provide evidence of your 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 statements showing Benefit payments. In order to support your referral please provide evidence of your 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. No information is required, please proceed to the next page. Health, Disability and Special Needs Health, Disability and Special Needs details Are you or your partner or anyone else in your 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 you consider yourself 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 your health, disability or special needs Are you currently on any medication? Yes No Please give more information Please provide the name and address of your Doctor Do you currently have a social worker? Yes No Do you qualify for Disability Living Allowance (DLA) or Personal Independence Payment (PIP) as a result of your disability? Yes No Do you have any medical specific accommodation needs? (optional) (for example, fridge required for medication, ground floor required due to limited mobility) You have stated that you consider yourself to have a health, disability or special need. In order for us to consider this as part of your 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 and family details 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 you subject to immigration control or restrictions? Yes No Do you have the right to work in the UK? Yes No Have you been granted indefinite leave to remain in the UK? Yes No You have stated that you have been granted indefinite leave to remain in the UK. As part of your 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 you have a partner that you wish to add to this referral? Yes No What is your partner's name? What is your partner's date of birth? (dd/mm/yyyy) Are you and your partner married? Yes No Is your partner in paid employment? Yes No Please provide details of your partner's employment. Include how many hours your partner works and average weekly/monthly wage. Please provide evidence of this on the upload page at the end of this form. Proof can consist of a wage slip or contact of employment. Is your partner in receipt of any Benefits? Yes No Please provide details of your partner's benefits. Include the name of the benefit you are in receipt of, and the average weekly/monthly amount received. You have stated that your partner is either in paid employment or receipt of benefits. As part of your assessment, we will need to see evidence of this. Please upload this on the evidence page at the end of this form. Does your partner have any support needs that we should be aware of? Yes No Please describe these support needs Do you have any children that reside with you 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. Eviction notice and rent arrears details Section 21 or a Section 8 eviction notice and rent arrears details Have you been issued with a Section 21 or a Section 8 eviction notice? Yes No In order to support your 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 your landlord may have issued you regarding your eviction on the evidence upload page at the end of this form. Does it state on the letter that you 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 you to leave by? (dd/mm/yyyy) Are you up to date with your rent? Yes No How much rent arrears are you in? Have you spoken to your Landlord regarding your Section 21 / Section 8? Yes No Please add any additional information regarding your Section 21 / Section 8 you believe might be useful for us to know (optional) Are you being evicted due to rent arrears? Yes No How much are your rent arrears in total? What date do your rent arrears date back to? (dd/mm/yyyy) What is the cause of your rent arrears? -- Please Select -- Rent increase Drop in income Reduction in benefit Rent unaffordable Other If 'Other', please specify Have you tried to come to a payment arrangement with your Landlord in an attempt to clear your arrears? Yes No Please provide us with information about the arrangement Are you in receipt of Housing Benefit or the housing element of Universal Credit? Yes No Are you in receipt of a Discretionary Housing Payment (DHP)? Yes No Please add any additional information regarding your 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 your 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 you to leave. What is the cause of your homelessness or soon to be homelessness? -- Please Select -- Parent asked me to leave my family home Friend / Family member asked to me to leave I have been sofa surfing and can no longer continue Relationship breakdown I have been advised by the police that I cannot return to my home SERCO support has come to an end I have been sleeping rough I am fleeing domestic abuse I cannot return to my home due to fire and flood I have just got out of prison or institution and have nowhere to go I have just been discharged from hospital and have nowhere to go I have left the forces and have nowhere to go I do not have a space of safety that I can return to Other If 'Other', please specify What date will you be homeless? (dd/mm/yyyy) Do you have an active Property Pool Plus account? Yes No It is important that you are actively using your Property Pool Plus account. You can improve your chances of being re housed by placing the maximum number of bids per week and widening the geographical area you are willing to accept a property in. The Housing Options Service are able to verify the number of bids you are making, and as part of your Personal Housing Plan will request that you place. the maximum number of bids each week to improve your chances of being rehoused. As you are already registered you should start actively bidding with immediate effect. The Housing Options Service may be able to use evidence that you have already provided when setting up your property pool plus account to support your Housing Needs Assessment. Do you give consent for the Housing Options Service to use evidence already provided for your Property Pool Plus account? Yes No It is important that you register for property pool as soon as possible. Once registered you should start actively bidding with immediate effect. You can improve your chances of being re-housed by placing the maximum number of bids per week and widening the geographical area you are willing to accept a property in. You can register for Property Pool online by visiting liverpool.gov.uk 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 to be provided with your application Evidence and documentation Please upload all your evidence here. If you cannot upload any of it now, you have 10 working days after submitting this form to send it to us using our additional evidence upload link. You will find an evidence upload facility available on the Liverpool City Council website. We cannot book you 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 you are employed, proof of employment (optional) This can be a contract of employment or recent wage slip If you are unemployed, evidence of unemployment (optional) This could consist of any of the following: award letters, screen shot of your universal credit journal, 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 you 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 you 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 you 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 you 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 your partner is either in paid employment or receipt of benefits. As part of your 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 your Section 21 or Section 8 eviction notice and any additional letters/notices your landlord may have issued you regarding your eviction. Evidence of rent arrears (optional) Please provide evidence of rent arrears and any additional letters/notices your landlord may have issued regarding your 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 that you are fleeing domestic abuse, cannot return home due to fire or flood or have nowhere to stay tonight, we will book you an emergency assessment without evidence. You may still have to provide evidence later, but your 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...