Online Referral Form

Retrieve Existing Application

All questions with an Asterix * must be completed for the online referral to be submitted.
If the service user doesn't have their own email address, please use their 'name@keystagehousing.co.uk'

Personal Details

Salutation *

First Name *

Last Name *

Email *

Date of Birth *

Gender *

Mobile *

Contact Details

Current Address Line 1 *

Address Line 2

Town / City *

County

Postcode *

Country *

Length of Stay at Current Address *

Phone Home

Phone Work

If you do not have a permanent address, please put 'No current address' in the contact details section

Service Scheme

Please select the service you require *

Additional Information

Service user National Insurance Number

Service user ethnic origin

Current status *

Last place of residence *

Factors involved in homelessness *

Has the service user previously been supported by HARRP? *

Is the service user currently engaging with other service? *

Does the service user have a care coordinator? *

Give details of the care coordinator in the box below

Is the service user currently under probation?

Please give details of the offence and the supervising officer/probation officer in the box below

Is the service user working more than 16hrs per week *

Is your client eligible for welfare benefits and lived in the UK for at least 5 years *

Does your client have proof of ID, NI, income and proof of residence if EEA national? *

Indicate which benefits your client receives *

Referral Agency Details *

Alternative Contact

First name

Last name

Relationship to you

Phone number

Referral Agency Details

Who has the user been referred by? *

Agency organisation details

First Name (Agency worker) *

Last Name (Agency Worker) *

Agency Phone *

Agency E-mail *

Risk Assessment

Keystage Housing requests that information regarding risk is shared with us so that we can appropriately support the needs of the service user and have a greater awareness of the aspects of their life where they may need support to make changes.

Think broadly about risk and please disclose important information to Keystage Housing that will help us to protect the service user and others who access our service, completing in the box: *

For HARRP referrals:

If you will not be supporting the service user to attend to the assessment, please upload a picture of the individual so we can verify them on arrival

Personal Details
Contact Details
Service Scheme
Additional Information
Alternative Contact
Referral Agency Details
Risk Assessment

By submitting your application you are agreeing to the following terms:

I conﬁrm that the information provided in this application form is true to the best of my knowledge.
I am happy for my details to be used for the purpose of referencing and for my chosen contacts to be contacted (including those outside the EEA), with personal information which has been provided in this form to allow them to verify the information about my earnings, dates of employment and previous tenancy term.
I agree to all data I submit being stored online in compliance with Arthur Online's GDPR and Privacy policies.

If you do not agree with any of these terms, do not submit your application form.