Northwest Simon - Agency Referral Form

Please note: * = necessary information

Agency Details* Agency:
* Name of person making the enquiry:
* Agency Phone No:
Agency's Email Address:

Client Details* Client's Name:
* Client's Contact Number:
Client's Email Address:
* Client's Gender:

* Client's Date of Birth:
* Please specify the household type of the client:

Client's Housing Details* Current Address:
Reasons for leaving current address (if applicable):
* Is the client currently at risk of homelessness:

If yes, do any of the following apply to the client.
Client has received noticed to quit:
Client has rent arrears:
Client has lost his/her rent supplement:
Other - please provide details:
* Does the client have a history of homelessness:
If yes please specify history of homelessness:
* Is the client registered with the local county council office:

Client's Accommodation NeedsNeed for Accommodation:
Need for Supported Accommodation:
Support to Maintain Current Accommodation:

Client's Physical Health Condition* Does the client have a physical health condition:

If yes, please answer the following questions.
What support does the client need around their physical health:
Is the client accessing treatment for this:
If yes please detail treatment:

Client's Mental Health Condition* Does the client have any mental health issues:

If yes, please answer the following questions.
What is the support required for this need:
* Is the client accessing treatment for this need:
If yes please detail treatment:

Client's Struggle with Addiction* Does the client struggle with addiction:

If yes, please answer the following questions
What support does the client need for their addiction:
* Is addiction treatment currently being accessed:
If yes please detail treatment:

Additional CommentsIf you wish to add comments regarding the client's situation or application, please do so below.:

I understand that the information disclosed on this form to Northwest Simon Community may be shared with necessary parties in the referral process once formal consent is given and that it may be electronically stored on Northwest Simon Community's internal system in line with Data Protection requirements.

* I Agree: yes

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