1Page 1 2Summary Progress Page 1 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 1: Referrer’s details Name Referrer Agency (e.g. GP, Youth Service...) Phone Email Relationship to service user Service user’s current housing situation A full description is required. 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 Consent By submitting this form, you confirm that you have had consent to do so from the service user. Consent I have consent from the service user to submit this form 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...