Tenant Referral Form

Retrieve Existing Application

This form is designed to collect the information that EHSL requires to understand the housing needs of the person being referred for supported housing, in order that EHSL can determine whether it is able to offer accommodation to the person whom an application has ever been made. Please ensure that every question is answered and that where supporting documentation is requested, that it is provided or made available. EHSL will be unable to offer accommodation or complete an application without the information required being provided.

Personal Details

Salutation *

First Name *

Last Name *

Email *

Date of Birth *

Gender *

Mobile *

National Insurance Number *

Type of accommodation tenant is moving from

Name of person submitting application

Relationship to Applicant

Housing Requirements

Is the applicant at risk of homelessness or have a deadline to move by?

If YES, by what date?

Which property or scheme is proposed for the applicant?

Is the applicant able to live with other people?

Are the following features required in the accommodation?

Wheelchair accessible

Level access

A bedroom for overnight staff

Detached accommodation

Please state any further essential requirements

Please note: the greater number of essential requirements means the more time you may have to wait for accommodation to be sourced or become available

Support requirements

Does the applicant have a diagnosed learning disability or mental heath condition?

What is the applicant's diagnosis? *

Is the applicant able to read and/or write? *

Does the applicant require information to be provided in a particular format? E.g. Easy-read, large font, simplified language, or another?

Is overnight care required? *

If YES, what sort of overnight

Which local authority is responsible for funding the care?

Please provide contact details for the applicants social worker

Name of social worker *

Telephone: *

Email: *

Please provide details of the proposed care package (i.e. number of support hours)

Does the applicant need help with any of the following?

Keeping their home clean

Making a complaint

Understanding their occupancy agreement

Reporting Maintenance Faults

Getting on with neighbours and co-tenants

Managing their money

Arranging contents insurance

Is there any history of tenancy issues that may affect the applicants ability to adhere to the terms of the occupancy agreement?Issues may be:- Non - payment of rent,- Noise complaints, - Anti-social behaviour, Damage. Please also state any criminal convictions(Please see note) *

Note: Schedule 2 Part II of the Housing Act 1988 reads: 'Grounds on which Court may Order Prossession........ 17. The tenant is the person or one of the persons to whom the tenancy was granted and the landlord was induced to grant the tenancy by a false statement made knowingly or recklessness by ---(a) the tenant or (b) a person acting on the tenants instigation.

Mental Capacity

Does the applicant have sufficient mental capacity to enter into a occupancy agreement? *

Mental Capacity Assessment or Best Interests Decision

Note: if a tenant lacks capacity into the agreement it can otherwise be signed by a power of attorney or deputy appointed by the Court of Protection. To comply with the Mental Capacity Act 2006 and the guildlines issue by the Court of Protection you will need to provide proof of the deputyship order issued by the Court of Protection. If an order cant be provided or the tenant has been assessed as lacking capacity to sign the agreement but a deputy hasn't been appointed a license may be prior to the order being received.

If the applicant lacks capacity, who will be signing the occupancy agreement?

Name and contact details

Order from the Court of Protection

Who is responsible for managing the applicants finances?

*Other

Name of organisation or person that manages the applicant's money

Telephone number

Email address

Is the applicant classed as 'Severely mentally impaired' for the purposes of council tax? *

Note: For Council Tax purposes it is considered as being severely mentally impaired if he or she has a severe impairment of intelligence and social functioning however causes which appears to be permanent

Income and Benefits

Is the applicant in receipt of the following welfare benefits(where applicable, Please fill in amount per week and date awarded in the text box below)

Disability Living Allowance (DLA) Care Component

Disability Living Allowance (DLA) Mobility component

Personal Independence Payment (PIP)

Employment and Support Allowance (ESA)

Income Support

Severe Disability Premium

Universal Credit

Please state any other benefits received, have been applied for, or you are waiting to hear about

Please provide details of any of the following owned by the applicant: Property, savings, investment, other capital *

Note: if you hold more than £16 000 saved you will not be eligible to claim Housing Benefit

Please provide any other relevant financial information here:

Does the applicant receive any income other than welfare benefits, such as wages or pension?

If YES, please provide details of any other income the tenant receives

Income Each Week

Does the applicant currently claim Housing Benefit? *

If YES, what is the claim reference number

Which local authority has awarded Housing Benfefit?

Consent to discuss application and share information

Are you happy to share the following information/documents with us, or authorise the relevant bodies to do so?

Note: This will assist EHSL to ensure the tenant is claiming the correct benefits exemptions and rate of Housing Benefit. If you grant consent to share this information but cannot provide it we will speak to the holders of this information (such as DWP Social Services Housing Benefit etc.) to obtain a copy

Welfare Benefit award notifications (from DWP) *

Support Plan (by Social Worker or Support Provider) *

Housing Benefit application information (From HB office) *

Placement Agreement (From Social Services or Support Provider) *

Confirmation of diagnoses (from doctor/medical staff) *

Other Information

Please upload a proof of ID

Please upload a proof of benefits

Please upload your most recent bank statement

Please use this section to provide any further information that you feel may be relevant

Signatures and Declaration

I declare that the information that I have provided is correct and complete

Name *

Relationship to current applicant *

Date *

If you wish to state tenants ethnicity, please do so here

Personal Details
Housing Requirements
Support requirements
Mental Capacity
Income and Benefits
Consent to discuss application and share information
Other Information
Signatures and Declaration

I understand and agree with the following:
- EHSL will use this information to determine whether it can offer supported housing to the person being referred.
- EHSL may use any information provided on this form in connection with this.
- EHSL and the nominated care provider will share information relating to any tenancy issued, including the rent amount and any matters that may constitute a breach of tenancy.
if inaccurate or incomplete information is provided and a tenancy is issued, any housing benefit award may be restricted below the level of the rent and the tenant will be required to contribute to the rent from their other income or savings.