Liverpool City Council

Before you start

Is the service user homeless or threatened with homelessness?

Yes
No

This referral process is for service users who are homeless or threatened with homelessness. For all other issues, please contact adult social care.

Please do not continue with this form, as it cannot be submitted.

Do you have consent to submit a referral on behalf of the service user?

Yes
No

You must get the service user’s consent to make this referral.

Please do not continue with this form, as it cannot be submitted.

Does the service user give consent to the Housing Options Service to make contact with them?

Yes
No

You must obtain the service user’s consent for Housing Options to contact them about this referral.

Please do not continue with this form, as it cannot be submitted.

Section 2: Service user’s details

Name

Known as - optional

Date of birth

National Insurance number - optional

Phone

c/o contact - optional

Is there an emergency contact?

Yes
No

Name of emergency contact

Emergency contact number

Relationship to service user

Does the service user have a partner?

Yes
No

Is the partner their emergency contact above?

Yes
No

Name of partner

Phone - optional

Does the service user have dependent children or anyone else who is reasonably expected to live with them?

Yes
No

Details To add details of another dependent, click 'Add dependent'.

Child's name

Date of birth

Add dependent

Section 3: Property details

Is the service user:

An owner/occupier
A tenant
A lodger
Of no fixed address

Landlord details

Is the service user’s current or last known address within the Liverpool City Council boundary?

Yes
No

Service user’s current or last address, including postcode

When must the service user vacate the property? - optional

Section 4: Health and welfare

Does the service user receive benefits?

Yes
No
Not known

Provide benefit details

Tell us about health issues you’re aware of for the service user or household occupants - optional

GP name and address - optional

Does the service user have a social worker?

Yes
No
Don't know

Has the service user been known to social care services?

Yes
No

Details of social worker

Housing Options Referral - Partner Agencies