Referral Form - Save the Family

Application Form -
Please read before proceeding

This is the referral form for supported accommodation at Save the Family, under the provision of their landlords, Hilldale Housing Association. Once the form has been completed and returned, the referrals process will be initiated.

– Save the Family are a Chester-based charity which provides residential accommodation and support for families that are
homeless (or at risk of becoming homeless) and who have multiple and complex needs.

– Please read the referral form carefully and provide honest responses to each of the questions. Any information provided within this form will be shared between both Save the Family and Hilldale.

– This sensitive information will be held in alignment with the Data Protection act 2018, along with our own data retention policy.

– You will be asked to provide photographic ID alongside your application, as well as 3 month’s Bank Statements and evidence of any benefits you receive.

– Please note, we will not be able to proceed with applications that do not grant us consent to gather and/or share information between services.

Main Applicant

First Name(s)

Surname

Previous Name(s)

Date of Birth

NI Number

Current Address & type of accommodation. (House, refuge, temporary accommodation etc.)

Contact Details

Details of anybody who will be living with the applicant

Surname

DOB

Gender

Relationship to applicant

Details of anybody who will be living with the applicant

Surname

DOB

Gender

Relationship to applicant

Details of anybody who will be living with the applicant

Surname

DOB

Gender

Relationship to applicant

Details of anybody who will be living with the applicant

Surname

DOB

Gender

Relationship to applicant

Is this a self referral?

Yes No

If answer is no please fill out the below

Organisation

How are you known to the applicant?

Contact details. (telephone & email)

Address & Postcode

I confirm that I have discussed this referral with the applicant

Date

APPLICANT TO COMPLETE (where possible): I confirm this referral has been discussed with me, and I agree to this application being sent to Hilldale Housing Association

Section 2: Support needs. Save the family provide supported accommodation for homeless families. To meet eligibility, families need to be:
• Homeless or at risk of becoming homeless.
• Have children in their care be on a rehabilitation plan to have children placed back in their care or be at least 25 weeks pregnant.
• Require support at the partnership plus level, which means they have two or more unmet needs that require additional support on top of the universal services.

Please X any of the support needs listed below that you require support with (you can tick more than one). This will help to assess eligibility and help to create a support plan if you are offered a place. For all support needs ticked, please include details:

Support Need (Present)

Mental Health Substance Misuse Social Care Involvement Care Leaver Domestic Abuse Rent Arrears or Debt Disability Young carer Other

Support Need (Historic)

Mental Health Substance Misuse Social Care Involvement Care Leaver Domestic Abuse Rent Arrears or Debt Disability Young carer Other

Are you aware of any criminal offences or charges in your name that may be present on a Police check?

Yes No

If yes, please provide details below (include any convictions and sentences, as well as the dates):

SECTION 3: Previous residence and reason for referral. Please provide details as to why you are making a referral to Save the Family:

Why is your current accommodation unsuitable?

What type / areas of support do you feel that you will benefit from?

Please provide details of your current residence: Which area do you currently live in?

Type of accommodation

Who is your landlord?

Do you live alone or share with others?

How long have you lived there?

Is this your permanent home?

Do you receive housing benefit at this address?

Accommodation Requirements - How many bedrooms will you require?

Do you have any mobility problems, health problems or disabilities that may require adaptations to an accommodation?

Yes No

If yes, please provide details

Section 4: Professional - Are you, or have you been supported by any other professionals? Involvement and consents.

Yes Previously No

If yes, please provide details below (examples may include social services, mental health services, debt services, children’s support services etc.):

Organisation

Relationship to applicant

Contact Number

Email Address

Please read the following statement regarding your information being shared between services:
I hereby give my permission for Save the Family and Hilldale Housing Association to share personal information with other service providers in connection with my care, including accessing and sharing my medical, and if applicable, mental health and police record information gathered about me, in order to carry out their landlord duties. As such my rights under the Data Protection Act 2018 will not be affected and my landlord will adhere to the General Data Protection Regulation Guidelines to protect my personal information.

Statement of Consent:
• I understand that personal information is held about me.
• I have had the opportunity to discuss the implications of sharing or not sharing information about me.
• I agree that personal information about me may be shared and gathered from the following agencies (including but not limited to):
• My Local Authority’s Housing Benefits Department
•NHS and other Health Services, including my GP practice
•Early Intervention Service including the police
•Adult Services
•Mental Health Services
•Education Support Services
•Social Care
•Voluntary Sector Organisations, such as Age Concern, Mind
•Housing Providers

Are there any agencies or individuals that you DO NOT want us to gather or share additional information with? If so, please include details below:

Having read and understood the above statement, I agree to my information being gathered and shared between services

If this application has been completed by a professional/other, the person being referred must provide consent to their information being gathered and shared between services.

Section 5: Demographic - ethnicity/diversity monitoring.

Save the Family is committed to equal opportunities and diversity. It is determined that in its provision of services and as an employer it will ensure equality of opportunity for all, regardless of age, race, gender (including gender reassignment), disability, marital status, sexual orientation, or religion or personal belief.

To help us implement and monitor this policy please could you provide us with the following information: Gender

Male Female Intersex Non-Binary Prefer not to say

If you prefer to use your own gender identity, please write in:

Is the gender you identify with the same as your gender registered at birth?

Yes No Prefer not to say

Age

16-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Prefer not to say

What is your ethnicity? Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box - Asian or Asian British

Indian Pakistani Bangladeshi Chinese Prefer not to say

Any other asian background, please write in:

Black, African, Caribbean or Black British

African Caribbean Black British

Any other black, african or caribbean background, please write in:

Mixed or multiple ethnic groups

White and Black Caribbean White and Black African White and Asian Prefer not to say

Any other mixed or multiple ethnic background, please write in:

White

English Welsh Scottish Northern Irish Irish British Gypsy or Irish Traveller Prefer not to say

Any other white background, please write in:

Other ethnic group

Arab Prefer not to say

Any other ethnic group, please write in:

Do you consider yourself to have a disability or health condition?

Yes No Prefer not to say

What is the effect or impact of your disability or health condition on your work? Please write in here:

What is your sexual orientation?

Heterosexual Gay Lesbian Bisexual Asexual Pansexual Undecided Prefer not to say

If you prefer to use your own identity, please write in:

What is your religion or belief?

No religion or belief Buddhist Christianity Hindu Jewish Muslim Sikh Prefer not to say

If other religion or belief, please write in:

What is your marital status?

Single Married Civil Partnership Separated Divorced Widowed Prefer not to say

Section 6: Financial information for housing benefit

Do you recieve/have you applied for? Universal Credit

Rate
*Tick as appropriate

Value

Frequency

Start Date

Income Support, Income-based JSA, Pension Credit?

Rate
*Tick as appropriate

Value

Frequency

Start Date

Employment & Support Allowance (ESA) Please specify the components you recieve

Rate
*Tick as appropriate

Assessment Phase Main Phase Work Related Group Support Group Contribution Based Income Based

Value

Frequency

Start Date

Disability Living Allowance (DLA) - Care?

Rate
*Tick as appropriate

Higher Medium Lower

Value

Frequency

Start Date

Disability Living Allowance (DLA) - Mobility?

Rate
*Tick as appropriate

Higher Lower

Value

Frequency

Start Date

Personal Independence Payment (PIP) - Mobility?

Rate
*Tick as appropriate

Enhanced Standard

Value

Frequency

Start Date

Personal Independence Payment (PIP) - Daily Living?

Rate
*Tick as appropriate

Enhanced Standard

Value

Frequency

Start Date

Attendance Allowance?

Rate
*Tick as appropriate

Value

Frequency

Start Date

Child Benefit?

Rate
*Tick as appropriate

Value

Frequency

Start Date

Any other benefits or allowances?(Please specify)

Rate
*Tick as appropriate

Value

Frequency

Start Date

Do you have any income from employment?

Rate
*Tick as appropriate

Value

Frequency

Start Date

Do you recieve any money from any other sources? Please give details below

Rate
*Tick as appropriate

Value

Frequency

Start Date

Do you have any interest in any property /land/caravan/mobile home/investments? Please give details

Do you have any capital and/or savings? Please detail

Bank Details - Name of Bank/Building Society

Sort Code

Account No.

Balance

Applicant Declaration

1. I confirm that the information provided in this form, is accurate. Failure to disclose any relevant information may lead to my application being suspended, in accordance with Hilldale’s Allocation and Lettings Policy.

2. If following my re-housing, I understand that information obtained found to be in breach of Hilldale’s Allocation and Lettings Policy, Hilldale Housing Association Ltd may commence proceedings against me (the applicant) on the grounds of obtaining my tenancy by deception.

The above declaration has been explained to me by:

Relationship e.g., Family member, Advocate, Appointee, Social Worker, Other (please state)

Name

Signed & Date

Contact Details

Section 7: Form completion and submission.

Thank for you for taking the time to complete this form and begin a referral into Save the Family. Any information included within this form will be kept under the standards of the Data Protection Act 2018.

Please be aware, that you can withdraw from this process at any time by contacting any the following email addresses. If you would like to be withdrawn from consideration AND have your information removed, please make it explicitly clear in your email.

If you require any further information as to our referrals process, or an update regarding your application, please contact us via the email links included below. Again, it is recommended that photographic ID, Bank statements and proof of benefits be included alongside your application.

Please return this form and any accompanying documents to the following addresses:
• billy.henry@savethefamily.uk.com (Referrals Coordinator).
• referrals@savethefamily.uk.com
• info@savethefamily.uk.com

Application Form - Please read before proceeding

Application Form -
Please read before proceeding