rEFERRAL aPPLICATION FORM "*" indicates required fields Applicants Personal DetailsFull Name* Current address with postcode* National Insurance Number* Nationality* Age* Ethnicity* Gender* Religion* Applicants Contact DetailsTelephone Secondary phone Email Applicants Personal CircumstancesDo you smoke* Yes No If yes how many per day/week? Do you Drink Alcohol?* Yes No If yes what type and how often? Do you take drugs?* Yes No If yes what type and how often? Do you have a criminal record?* Yes No If yes what type and how often? Do you have any mental health condition (Anxiety, Depression, Bi Polar etc)?* Do you have any physical health conditions (Arthritis, Asthma etc)?* What proof of ID do you have (Passport/Driving License/Birth Certificate/Citizen ID etc)* What is the reason you wish to move? What is your source of income: What benefits are you on?* Next of Kin DetailsNext of Kin Name Next of Kin Address Next of Kin Contact Current LandlordFull Name of Landlord Full Postal Address of Landlord Contact Number of Landlord Contact Email of Landlord Probation OfficerFull Name of probation officer Full Postal Address of Probation Officer Contact Number of Probation Officer Contact Email of Probation Officer CPN WorkerFull Name of CPN Full Postal address of CPN Contact Number of CPN Worker Contact Email of CPN Worker Social/Key WorkerFull Name of CPN Contact Number of social/key worker Preferred areaWhat areas would you prefer to be housed in? Enter Area Is a professional filling this form in on behalf of the applicant?* Yes No Professionals DetailsFull name of professional Organisation Name Organisation Email Organisation Telephone Reason for referral Opt InOpt in I or the professional in charge of my housing agree that the information contained in this referral form is true and accurate and consent to it being used as part of the assessment and risk process. By ticking the box, I or the professional in charge of my housing agree that all the information provided is true and will inform the provider of any changes. I or the professional in charge of my housing also understand that Birmingham Housing have the right to refuse support if any of the information provided is incorrect/false.Opt in I am ticking the box to allow Birmingham Housing to carry out checks on the information I have provided through contact with other agencies, e.g. Medical Professionals, probation services, social services etc. I am ticking the box to say I give permission to share information about me with other agencies. SUPPORTED HOUSING PROVIDER INTENSIVE MANAGEMENTEXPERIENCE
