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Referral Form
Refer individuals for supported housing with Easy Housing Association.
Fill in form
Please leave blank:
Step 1
Our properties are located in the following areas: Erdington, Aston, Small Heath, Kings Heath, Handsworh, Alum Rock
Method of Referral
Organisation:
Yes
No
Self-referral:
Yes
No
Friends or Family:
Yes
No
Other (If applicable please provide more info):
Tenant Information
Full Name:
Email Address:
Are you in Receipt of any Benefits?
Yes
No
Date of Birth:
National Insurance (NI) Number:
Do you have any dependents to be rehoused with you?
Yes
No
If Yes, We will not be able to provide accommodation as all our properties are for single people.
Current Address:
Ethnicity:
Please note, we provide shared accommodation for single adults:
Yes
No
Please confirm suitability
Contact Number:
Current Status in the UK:
Step 2
Housing Needs
Reason for Referral:
Homelessness
Threat of Homelessness
Domestic Violence
Financial Difficulties
Other
Current Housing Situation:
Staying with Friends/Family
Temporary Accommodation
Private Rental
Other
Desired Location(s):
Step 3
Support Needs
Support Needs:
Yes
No
Current Support Services:
Social Services
Mental Health Services
Substance Misuse Services
Other
Are there any known vulnerabilities or specific requirements? eg. physical disabilities, mental health issues:
Please confirm:
I confirm that the information provided is accurate and that the tenant has given consent for this referral.
Comments:
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