Referral Form
Please fill this in with as much detail as you can so that we are able to provide our hosts with an accurate picture of their potential guest. Welcoming a stranger into your home is not always easy, so the more information we can gather the more likely it is that the hosts will agree to the placement.

If you would prefer to download a PDF copy of this form, please click here: PDF form.

Your details

Please enter your details here.
Key worker/support worker name

Client details

Please complete details about your client here.

Additional Information

(eg CG decision agreed and exiting NRM, vulnerable to street homelessness)
If yes, approximately how many per day?
If yes, how regularly?
(e.g. proximity to mosque or access to certain types of foods)
*Please note it is the responsibility of the referrer to provide transport and their belongings.
*If an application to NASS, LA housing or other types of accommodation has been made, please provide the date of the application.

Needs Assessment

This helps our matching process
Please outline amounts if so
(please include history of suicide attempts or self harm)

Risk Assessment

Declarations and consent

Referrer:
I have explained the Hope at Home hosting scheme to the person I am referring, and they understand this is a voluntary arrangement between both parties which may be terminated at any point. I have explained the referral process and they understand they will be provided with information of potential hosts, including house-rules, before making any final decision. I agree, to the best of my knowledge, the information within this referral form is correct.
Please ensure that the client signs the consent and sharing information section as below. We cannot process the referral without this.

Referred client: Data Consent Form

I authorise Hope at Home to hold on file details of my circumstances and other personal details, whether provided by myself or others, for the purposes of assisting with my housing situation and related issues.

For the purposes of the General Data Protection Regulations 2018, the data controller is Hope at Home.

Please confirm the following with the client.

• I am happy for Hope at Home to keep written and electronic information about me and to keep in touch with me in accordance with their data privacy notice.
• I understand that this information may be shared with hosts or external agencies in order to make the placement or safeguard anyone at risk.
• I am happy for Hope at Home to contact other agencies, where it is necessary, for the purposes of my support.
• I agree that the information provided in this referral form is accurate.
If you cannot obtain the client's signature, please leave this blank and enter their name above, having ensured the above data protection information has been relayed to them in full.