YMCA St Paul's Group Referral Form

Referral date

Personal Details

Title 

Please select... Dr Miss Mr Mrs Ms Mx

First Name

Last Name

Preferred name

Referral Type *

Please select... Direct Referral Kingston upon thames Ealing Hammersmith & Fulham Harrow Hillingdon Merton Waltham Forest Emergency bed referral Mother and baby Slough Housing Demand Team Slough Young Persons Project Social Services Placement Waltham Forest Rough Sleeper Projects Waltham Forest Young Persons Project

Select Project *

Please select... Mitcham Mypad 20 Parsons Green South Ealing hostel Ventura House Walthamstow Hostel Ealing Common Greenford Hanwell Northolt Grange South Ealing hostel Supported Lodgings Chalvey Ealing Common Surbiton hostel Uxbridge Parsons Green Roxeth Gate Supported lodgings Supported Lodgings Uxbidge Ventura House Surbiton Hostel Wimbledon Hostel Greenford Hanwell Northolt Grange Roxeth Gate Chalvey Britwell Slough Young Persons Project Chalvey Ealing Common Greenford Hanwell Northolt Grange Roxeth Gate South Ealing hostel Uxbridge Walthamstow Hostel Heavitree Court Marsham Court Stephens House

Mobile number

If you do not have one, please enter N/A

Email

If you do not have one, leave blank

Date of birth known

Please select... Yes No Client did not wish to disclose

Date of birth

NI number known

Please select... Yes No - client does not know it No - client does not have one Client did not wish to disclose

NI number

Gender 

Please select... Female Male Agendered Genderfluid Genderqueer Gender non-conforming Intersex Non-binary Third gender Did not ask Client did not wish to disclose

Sexual orientation 

Please select... Asexual / Ace Bisexual Gay Heterosexual Lesbian Pansexual / Pan Queer Unsure Other Did not ask Client did not wish to disclose

Primary nationality

Please select... Afghan Albanian Algerian American Andorran Angolan Anguillan Citizen of Antigua and Barbuda Argentine Armenian Australian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Belarusian Belgian Belizean Beninese Bermudian Bhutanese Bolivian Citizen of Bosnia and Herzegovina Botswanan Brazilian British British Virgin Islander Bruneian Bulgarian Burkinan Burmese Burundian Cambodian Cameroonian Canadian Cape Verdean Cayman Islander Central African Chadian Chilean Chinese Colombian Comoran Congolese (Congo) Congolese (DRC) Cook Islander Costa Rican Croatian Cuban Cymraes Cymro Cypriot Czech Danish Djiboutian Dominican Citizen of the Dominican Republic Dutch East Timorese Ecuadorean Egyptian Emirati English Equatorial Guinean Eritrean Estonian Ethiopian Faroese Fijian Filipino Finnish French Gabonese Gambian Georgian German Ghanaian Gibraltarian Greek Greenlandic Grenadian Guamanian Guatemalan Citizen of Guinea-Bissau Guinean Guyanese Haitian Honduran Hong Konger Hungarian Icelandic Indian Indonesian Iranian Iraqi Irish Israeli Italian Ivorian Jamaican Japanese Jordanian Kazakh Kenyan Kittitian Citizen of Kiribati Kosovan Kuwaiti Kyrgyz Lao Latvian Lebanese Liberian Libyan Liechtenstein citizen Lithuanian Luxembourger Macanese Macedonian Malagasy Malawian Malaysian Maldivian Malian Maltese Marshallese Martiniquais Mauritanian Mauritian Mexican Micronesian Moldovan Monegasque Mongolian Montenegrin Montserratian Moroccan Mosotho Mozambican Namibian Nauruan Nepalese New Zealander Nicaraguan Nigerian Nigerien Niuean North Korean Northern Irish Norwegian Omani Pakistani Palauan Palestinian Panamanian Papua New Guinean Paraguayan Peruvian Pitcairn Islander Polish Portuguese Prydeinig Puerto Rican Qatari Romanian Russian Rwandan Salvadorean Sammarinese Samoan Sao Tomean Saudi Arabian Scottish Senegalese Serbian Citizen of Seychelles Sierra Leonean Singaporean Slovak Slovenian Solomon Islander Somali South African South Korean South Sudanese Spanish Sri Lankan St Helenian St Lucian Stateless Sudanese Surinamese Swazi Swedish Swiss Syrian Taiwanese Tajik Tanzanian Thai Togolese Tongan Trinidadian Tristanian Tunisian Turkish Turkmen Turks and Caicos Islander Tuvaluan Ugandan Ukrainian Uruguayan Uzbek Vatican citizen Citizen of Vanuatu Venezuelan Vietnamese Vincentian Wallisian Welsh Yemeni Zambian Zimbabwean Did not ask Prefers not to say

Ethnic origin

Please select... Asian / Asian British: Bangladeshi Asian / Asian British: Chinese Asian / Asian British: Indian Asian / Asian British: Other Asian / Asian British: Pakistani Black / Black British: African Black / Black British: Caribbean Black / Black British: Other Mixed / multiple: Other Mixed / multiple: White & Asian Mixed / multiple: White & Black African Mixed / multiple: White & Black Caribbean Other ethnic group: Arab Other ethnic group: Other White: English / Welsh / Scottish / Northern Irish / British White: Gypsy or Irish Traveller White: Irish White: Other Did not ask Client did not wish to disclose

Preferred language

Please select... English Acholi Albanian Amharic Arabic Bengali British Sign Language (BSL) Bulgarian Cantonese Czech Dari Eritrean Estonian Farsi / Persian French German Greek Gujarati Hungarian Italian Krio Kurdish Latvian Lingala Lithuanian Mandarin Ndebele Pashto Polish Portuguese Punjabi Romanian Russian Serbo-Croat Slovakian Slovenian Somali Spanish Swahili Swedish Tamil Tigre Tigrinya Turkish Urdu Vietnamese Welsh Yoruba Did not ask Client did not wish to disclose

Translator Required?

Religion 

Please select... Agnostic Atheist Buddhist Christian (all denominations) Hindu Jewish Muslim Sikh Any other religion Not sure No religion Did not ask Client did not wish to disclose

Immigration status 

Please select... UK national EEA national Asylum appellant Asylum seeker British citizen + failed HRT Discretionary leave to remain (DLR) EEA citizen + failed HRT Exceptional leave to remain (ELR) Failed asylum seeker Humanitarian protection (HP) Indefinite leave to remain (ILR) Limited leave to remain Limited leave to remain + NRPF Overstayer Pre-settled status Refugee Settled status Other Did not ask Client did not wish to disclose

Immigration status - other

Marital status

Please select... Married Widowed Separated Divorced Single

Food Allergies

Food allergies or dietary requirements

Referral Agency Details

Applicants Local Connection

Please select... Barking & Dagenham Barnet Bexley Brent Bromley Camden City of London Croydon Ealing Enfield Greenwich Hackney Hammersmith & Fulham Haringey Harrow Havering Hillingdon Hounslow Islington Kensington & Chelsea Kingston upon Thames Lambeth Lewisham Merton Newham Redbridge Richmond upon Thames Southwark Sutton Tower Hamlets Waltham Forest Wandsworth Westminster

Name of Local Authority or Other Organisation Making This Referral

Referreral Officer Details

Please include details of the professional/volunteer who is making this referral

Referral Agency email address

A copy of the responses will be emailed to this address

Referral Agency Telephone

Relationship to applicant

Please select... Professional - Local Authority Housing Professional - Supporting Agency Professional - Physical or Mental Health Practicioner Professional - Other Housing Provider

Entitled to housing benefit

Please select... Yes No

Applicant registered on LA housing list

Please select... Yes No

If yes, date registered

If yes, registration number

Applicant with a statutory duty owed

Please select... Found statutorily homeless by a housing authority and not owed a homelessness duty Found statutorily homeless by a housing authority and owed a homelessness duty Not found statutorily homeless by a housing authority but considered to be homeless by service provider

Next of Kin

Name

Relationship to Applicant

Please select... Aunt Boyfriend Brother Carer Cousin Daughter Daughter-In-Law Father Father-In-Law Friend Foster Father Foster Mother Foster Parent Girlfriend Granddaughter Grandfather Grandmother Grandson Guardian Husband Mother Mother-In-Law Neighbour Nephew Neice Other Parent Partner Resident Sister Son Son-In-Law Step-Daughter Stepfather Stephmother Step-Son Uncle Wife

Phone

Email

Housing Situation

How long have you known the applicant

Reason for application

Please provide a brief description of the main reasons why you are making this referral

Are you currently homeless

Please select... Yes No

Present accommodation

Please select... Probation hostel Bed and breakfast Direct access hostel Foyer Home office Asylum Support Hospital Housing association general needs tenancy Housing for older people Living with family Living with friends Local authority temporary accommodation Local authority general needs tenancy Mobile Home / Caravan Owner occupation (Low cost home ownership) Owner occupation (Private) Prison Private sector tenancy Residential care home Rough Sleeping Staying with friends Staying with family Short life housing Supported housing Tied housing or rented with job Women’s refuge Young people leaving care Other

Main Reason For Leaving Last Settled Home

Please select... End of assured shorthold tenancy - no fault End of assured shorthold tenancy - eviction or tenant fault End of fixed term tenancy - no fault End of fixed term tenancy - eviction or tenant fault Discharged from long stay hospital or similar institution Discharged from prison Left home country as a refugee Loss of tied accommodation Asked to leave by family or friends Death of household member in last settled home Relationship breakdown (non-violent) with partner Moving nearer to family, friends or school Moving nearer to work Domestic abuse - previous joint tenancy with partner Domestic abuse - other Hate crime Racial harassment Other problems with neighbours Couldn't afford tenancy renewal fee Couldn't afford rent increase Couldn't afford rent or mortgage - employment Couldn't afford rent or mortgage - welfare reforms Couldn't afford rent or mortgage - other Repossession Property unsuitable - overcrowding Property unsuitable - ill health or disability Property unsuitable - poor condition Moving to supported accommodation Moving to independent accommodation Under occupation - no incentive Under occupation - offered incentive to downsize Tenant prefers not to say Don't know

Previous Accommodation

Date from: 1

Date to: 1

Address: 1

Landlord details: 1

Date from: 2

Date to: 2

Address: 2

Landlord details: 2

Date from: 3

Date to: 3

Address: 3

Landlord details: 3

Income

Employment status

Please select... Unemployed Working - Part Time Working - Full time Student

Income

Universal CreditEmploymentNo Recourse to Public Funds(Check all that apply)

Support Needs

Support Needs

Mental HealthPhysical HealthOffendingSubstance & Alcohol useEducation, Training & EmploymentHomeless In Need Of SupportDomestic ViolenceOther

Other - Details

If you choose 'Other', please provide further details

Mental Health

Mental Health Diagnosis

Mental Health Medication

Physical Health 

Physical Health Diagnosis

Physical Health Medication

Offending

Previous conviction details

Offences relating to violence or weapons

MAPPA or PPO

MAPPA or PPO details

Currently on probation

Details of probation & probation officer

Have you been convicted of arson

Arson details

Convicted of sexual offence

Sexual offence details

Do You Receive Support From Other Organisations / Professionals?

Please provide details of any professionals who are supporting this client (mental health worker, drug & alcohol worker etc)

Are you a former YMCA resident

If yes, which site

Please select... 16 Victoria Avenue 18 Balaclava Road 18 Victoria Avenue Ealing Common Supported Housing East London - 4 Second Avenue East London - Edward House East London - Stephen's House East London 19 Woodlands Road East London 247 Fulbourne Road East London 26 Spruce Hills East London 279 Fulbourne Rd East London 38 Spruce Hills East London 5 Shernall Street East London Albert Road East London Brookscroft East London Clockworks East London Hostel East London Heavitree Court East London Marsham Court East London MYPAD 10 East London MYPAD 20 Greenford Supported Housing Hanwell Supported Housing South Ealing Hostel Ventura House Supported Housing Roxeth Gate Supported Housing Northolt Supported Housing Uxbridge Supported Housing Slough Chalvey Hostel Slough Britwell Hostel Surbiton Hostel Mitcham Housing Wimbledon Hostel Parsons Green

Reasons for leaving YMCA

Please select... End of license agreement Moved into private rented sector Moved to local authority tenancy Evicted - ASB Evicted - Rent arrears Taken into custody Other

Relationship to any current resident

Please select... Yes No

Proof of ID attached

Proof of income attached

Upload Files

ID

Proof of Income

If no proof of income is available, please provide statement or written evidence to confirm this

Mental Health Report

GP Report

Other Document