Supported housing referral form

We work in partnership with local landlords to deliver a quality accommodation and support services in Birmingham. This accommodation is usually provided to those referred to us by local authorities, the police, health and social care professionals, hospitals, drug and alcohol Services, charities, faith institutions and the like.

Applicants can also refer themselves using the below form.

Referrer Details (if applicable)

Referrer full name

Referrer telephone number

Referrer email address

Reason for referral

Applicant details

Full name

Email

Confirm email

Marital status

Gender

Current address (if applicable )

Date of birth

National Insurance number

Religion

Nationality

Employment status

Ethnic origin

Living circumstances ( Tick the box (es) that apply )

Living with parents

Living with family/friends

Living in council accommodation

Living in housing association accommodation

Living in temporary accommodation

Currently in hospital

Living in residential care home

Living in private rented property

Just left hospital/treatment centre

Just left prison

Sleeping on the streets

No fixed address

Living with parents

Other, please specify in the below textfield

Personal circumstances ( Tick the box (es) that apply )

Do you smoke?

Do you Drink Alcohol

Do you take drugs

Do you have a criminal record?

Do you have any mental health condition (Anxiety, Depression, Bi Polar etc)?

Do you have any physical health conditions (Arthritis, Asthma etc)?

Preferred language

Interpreter required

Communication needs, such as Large Print Braille, Mini Com Audio or Signer Translation

Dependants and their ages

Preferred method of Contact ( Telephone, post,email or text )

What areas would you prefer to be housed in Birmingham?

Message

I declare that the information I have submitted on this form is correct.

Submit