info@xenialhousing.co.uk
Test
Home
About
Services
All Services
Mental Health
Alcohol & Drugs
Homelessness
Domestic Violence
Landlords
Residents
Maintenance Request
Complaints Form
News
Start A Referral
Contact Us
Office Address
1110 Elliott Court, Coventry Business Park, Herald Avenue, Coventry, CV5 6UB
info@xenialhousing.co.uk
(00) 2500-123-4567
Pinterest
Social List
Start an Online Referral
Complete and submit our referral form online to start the referral process.
This is the fastest method to start the referral process
A member of the team will get back to you within 24 hours to follow up your referral.
It is button
Thank you for completing the online referral form. We will respond to you shortly.
1
1
https://xenialhousing.co.uk/wp-content/plugins/nex-forms-lite
false
message
https://xenialhousing.co.uk/wp-admin/admin-ajax.php
https://xenialhousing.co.uk/online-referral
yes
1
fadeIn
fadeOut
Sections marked with * are Mandatory
SECTION 1 - REFERRAL AGENCY DETAILS
*Referral Agency
*Email
*Landline Number
Mobile Phone Number
*Reason for Referral
SECTION 2 - APPLICANT DETAILS
Title
*Applicant Name
*Address
*Postcode
*D.O.B
*Gender
*Contact Number
*N.I. Number
*Benefit Status
*Immigration Status
*Date of Entry to UK
*Ethnicity
Next of Kin (& Relationship)
Next of Kin Address
Next of Kin Contact Number
SECTION 3 - PREVIOUS ADDRESS HISTORY (INCLUDING SUPPORTED ACCOMMODATION)
Address
Dates / Duration
Type of Occupancy, i.e. Private, Supported
Reason for Leaving, i.e. Arrears, ASB
SECTION 4 - APPLICANT MEDICAL BACKGROUND / HISTORY
Social Worker/ CPN/ Probation Officer or Other Relevant Professional/s
Address
GP Name and Address (If Applicable)
*Has Client Ever Been: Detained / Sectioned Under The Mental Health Act?
.
Yes
.
No
If Yes, Please Provide Details:
SECTION 1 – REFERRAL AGENCY DETAILS
Address
Physical Health History
Present Medication and/or Treatment
*Criminal Convictions/ Community Orders (This Information Must Be Provided)
Any Other Relevant Infomation
SECTION 5 - SUPPORT GROUP / SUPPORT NEEDS
Support Group Y/N
Support Needs: Please Provide Details of Level and Type of Support Required
Mental Health Problems
.
Yes
.
No
Single Homeless with Support Needs
.
Yes
.
No
Primary Health Care, Mental Health or Drug/Alcohol Services
.
Yes
.
No
Accommodation / Housing
.
Yes
.
No
Domestic Violence/Abuse
.
Yes
.
No
Other (Please specify)
.
Yes
.
No
*SECTION 6 - AUTHORISATION - APPLICANT
? 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.
? I give my permission for the outcome of this referral to be explained to the referral agency
? I agree to participate in a support package including support planning and assessment
*Applicant
*Date
.
*Please check the box to consent to the above
SECTION 7 - AUTHORISATION REFERRAL AGENCY
Name of Person Making Referral
*Date
Position in Company
.
*Please check the box to consent to the above
SECTION 7 - SUPPORTING DOCUMENTATION / ADDITIONAL INFORMATION
Please List Documents To Be Attached / Additional Information:
PLEASE NOTE: XENIAL HOUSING IS AN EQUAL OPPORTUNITIES HOUSING PROVIDER.
HOWEVER WE RESERVE THE RIGHT TO REFUSE REFERRALS WITH A HISTORY OF ARSON (INSURANCE REGULATIONS) AND SEX OFFENCES
Submit
Powered by
NEX-Forms
