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Referral Form Preview

Hi Referrals Team,

Please see below.

1. Applicant's Details

Please complete this form as fully as you can.

1.1 - Referral Date(Required)

DD slash MM slash YYYY

1.2 - Date Placement Required(Required)

DD slash MM slash YYYY

1.3 - Please give reasons why supported housing is required and not general needs housing(Required)

Please enter any additional info here

1.4 - Preferred Supported Housing Service(Required)

View details of service at www.langleytrust.org/our-services/supported-housing

1.5 - Personal Details

Forename/s(Required)

Surname(Required)

Title(Required)

Also known as

Marital Status(Required)

Address(Required)

Street Address Town / City Post Code

Phone Number(Required)

Date of Birth(Required)

DD slash MM slash YYYY

National Insurance Number(Required)

Gender(Required)

Male

Female

Transgender

1.6 - Please tick if any of the following apply to your current accommodations(Required)

Tick at least one answer

Prison

Rented - local authority/social landlord

Rented - private sector

Approved Premises

CAS2/3

Family/Friends

No Fixed Abode

None of the above

2. Previous Accommodation and Rent Arrears

2.1 - Please provide details of your previous addresses(Required)

Type N/A in each box if there are none

Address

Did you hold tenancy? (Yes/No)

Arreas or debt from this address? (Yes/No)

Reason for Leaving

2.2 - Do you currently have any rent arrears?(Required)

Yes

Please provide details(Required)

2.3 - Did you have arrears in a previous accommodation?(Required)

Yes

Please provide details(Required)

2.4 - Any other debt or financial problems?(Required)

Yes

Please provide details(Required)

2.5 - Owning A Property

Do you or your partner currently own a property?(Required)

Yes

Have you or your partner owned a property in the last 5 years?(Required)

Yes

Name of the owner(Required)

Address of the property(Required)

Address Town / City Post Code

How much is the property worth?(Required)

Are you in receipt of Universal Credit?(Required)

Yes

Are you eligible for Universal Credit?(Required)

Yes

3. Current Legal Status

3.1 - Tick all that apply(Required)

Automatic Conditional Release

Bail/Remand/Parole

Home Dentention Curfew

Imprisonment for Public Protection

Life Licence

Sexual Harm Prevention Order

Sex Offender Register

Youth Offending Institute

3.2 - History of Offending:

Index Offence(Required)

Date of Offence(Required)

DD slash MM slash YYYY

Current Sentence(Required)

Sentence Start Date(Required)

DD slash MM slash YYYY

Release Date (if custodial sentence)(Required)

DD slash MM slash YYYY

Sentence Termination Date(Required)

DD slash MM slash YYYY

Licence End Date(Required)

DD slash MM slash YYYY

Post Sentence Supervision End Date(Required)

DD slash MM slash YYYY

MAPPA Level(Required)

MAPPA Category(Required)

Any gang affiliations?(Required)

Yes

3.3 - Details of current offence(Required)

What happened? Who was involved? What were the motivations/triggers to the offence?

Upload OASys document with details of the current offence

Max. file size: 100 MB.

3.5 - Full list of Previous Convictions(Required)

Type N/A if none or if you can provide MG16 document below

Conviction Information

Date of Offence

Date of Sentence

Sentence Recieved

Upload MG16 with details of previous offences

Max. file size: 100 MB.

3.5 - Attitudes and Behaviours
Including during current/previous placements

In custody - can you tell us about their behaviour in this placement? Advise whether they received any warnings, or any positive reports.(Required)

History of/ current behaviour in the community (on licence, in other housing placements, engaging with other agencies, etc.)? How have they complied with periods of probation supervision?(Required)

3.6 - Offence Focussed/Behavioural Work

Have they completed any offence focused/behavioural work? If so, what? How have they engaged with this?(Required)

Type N/A if not

Risk to Children(Required)