Self-referral

Refer yourself

Tell us about yourself, your income, your housing history, your health and anything we need to know to find you the right home.

Before you start

Have these ready

Your National Insurance number and date of birth
Photo ID to upload
A screenshot of your Universal Credit journal payment statement
An “Entitled to” benefits calculation and an income and expenditure assessment
Your addresses for the last five years

Being referred by a council officer or key worker? They can use the referral form. Applying for a specific room? Use the form on its listing under available rooms.

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Thank you for your response. ✨

Applicant details

Applicant name

Current address: street address

Current address: address line 2

Current address: town or city

Current address: county

Current address: postcode

Applicant contact number

Date of birth

DD/MM/YYYY

NI number

Gender

Nationality

Preferred location

Reason for referral (brief reason and background details for applicant)

Universal Credit and other benefits

Are you in receipt of Universal Credit(required)

Yes No

Is this a telephone claim?

How much Universal Credit do you receive?

How often are you paid Universal Credit(required)

Once monthly Twice monthly Not receiving Universal Credit

What is the payment date of your Universal Credit?

What is the payment date of the second payment (if applicable)

Are you in receipt of any other benefits?

Complete the rows that apply. Please note: we do not accept Pension Credit.

PIP: how much?

PIP: payment date?

Employment Support Allowance (ESA): how much?

Employment Support Allowance (ESA): payment date?

Veterans Allowance: how much?

Veterans Allowance: payment date?

Carers Allowance: how much?

Carers Allowance: payment date?

LCW: how much?

LCW: payment date?

LCWRA: how much?

LCWRA: payment date?

Other benefit: how much?

Other benefit: payment date?

What element of your benefit do you receive, e.g. PIP – Daily Living/Mobility, ESA – Support Element?

What is the payment date of this benefit? (for example: 7th, 19th)

Do you have access to an online Universal Credit account?

Household and employment

How many children are in your household?

Are you in hospital/residential care, a prisoner, on strike, living abroad or a full time student?

Are you employed?

If YES, how many hours per week?

How much money do you earn per month before deductions

Do you receive disability or sickness benefit?

Common disability benefits are Attendance Allowance, Disability Living Allowance (DLA), Personal Independence Payment (PIP), Employment and Support Allowance (ESA), Universal Credit limited capability for work element (LCW/RA) and Statutory Sick Pay (SSP).

Are you ill or disabled but not claiming one of the disability benefits listed above?

Do you care for someone who is sick or disabled?

Other income and savings

Income from non-state pensions?

Income from Fostering Allowance?

Household savings or capital over £6,000?

If so, how much:

Income from spousal maintenance payments

Income from charity or voluntary sources

Do you own land or property?

Previous 5 year address history

Last 5 addresses.

Address 1

Address 1: address

Address 1: date/duration

Address 1: type of accommodation

Address 1: landlord details

Address 1: reason for leaving

Address 2

Address 2: address

Address 2: date/duration

Address 2: type of accommodation

Address 2: landlord details

Address 2: reason for leaving

Address 3

Address 3: address

Address 3: date/duration

Address 3: type of accommodation

Address 3: landlord details

Address 3: reason for leaving

Address 4

Address 4: address

Address 4: date/duration

Address 4: type of accommodation

Address 4: landlord details

Address 4: reason for leaving

Complete a benefits calculation at entitledto.co.uk and attach the result below.

Applicant medical background/history

Social worker, CPN or any other medical professionals

GP name

GP address line

GP town or city

GP county

GP postcode

Mental health history

Physical health history

Present medication or treatment

Any other relevant information

Probation Officer name & contact details if allocated

Next of kin or significant other

Next of kin first name

Next of kin last name

Next of kin contact number

Next of kin email address

Relationship to applicant

Next of kin address: street address

Next of kin address: address line 2

Next of kin address: town or city

Next of kin address: county

Next of kin address: postcode

Equality, diversity and inclusion

Please answer all of the below.

Does the applicant have any cultural, ethnic, religious or other specific needs?(required)

Yes No

Cultural, ethnic, religious or other needs: details

Does the applicant have any physical disability, accessibility or additional needs?(required)

Yes No

Disability, accessibility or additional needs: details

Authorisation

I give my consent to the disclosure of this information for the purpose of finding accommodation and to the disclosure of any supplementary information attached for housing purposes, in line with GDPR regulations.
I agree to participate in coaching services which are included as part of my tenancy agreement.

Do you agree to the statements above?

I consent to the above terms

Signature (type your full name)

Date

DD/MM/YYYY

Applicant details

Universal Credit and other benefits

Are you in receipt of any other benefits?

Household and employment

Other income and savings

Previous 5 year address history

Address 1

Address 2

Address 3

Address 4

Applicant medical background/history

Risk assessment

Safeguarding concerns

Other questions/concerns

Next of kin or significant other

Equality, diversity and inclusion

Authorisation