Fillable DUTY TO REFER FORM Date of referral (Mid Sussex District Council)

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DUTY TO REFER FORM Date of referral (Mid Sussex District Council)

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1
DUTY TO REFER FORM
Local Housing authority details
Date of referral
Please confirm the name of the local
housing authority that the individual or
household is being referred to
Do they have a local connection to the
receiving council (e.g. residence,
employment, immediate family)?
Pl
ease provide details
Details of the person & organisation making the referral
Referrer’s name
Role of person making the referral
Name of public authority making
the referral (e.g. prison, hospital
etc)
Phone number
Address of public authority
Email address
Name & contact details of any other
person or service to be contacted
for further information.
2
Details of the person or household being referred:
Name of person being referred
Are they known by any other
name? If so, please state:
Date of birth
National Insurance no.
Gender
Household composition (single
person, couple, family with children
or other adults)
Current address
Phone
Email
Household Details
Relationship
to applicant
Do they
live with
the
applicant?
Date of birth
Name of household member
3
Why are they homeless or threatened with homelessness? Please provide full details of the
circumstances which have led to this referral
Additional Information
What type of accommodation is the
individual or household currently living in?
What date are they likely to become
homeless?
If the service user is due to leave prison or
hospital, or is leaving the armed forces,
with no accommodation available, please
provide the planned release or discharge
date.
Please provide information about any
additional needs or risks that we need to
be aware of (this might include history of
rough sleeping, substance misuse)
Please provide full details if the individual
or household is at risk of violence or harm,
and where this risk is likely to occur.
4
Please provide information about any
physical or mental health needs affecting
the individual or household member.
Please include details of any treatment or
support they receive for these health
needs.
Please provide the contact details for any
other agencies or services that are
currently working with the individual or
household.
Please provide any additional relevant
information, including any known risks to
staff or other service users.
CONSENT AND DECLARATION
Person being referred I, ………………………………………, consent to this information being passed to
……………………………………… (Council name) and give them permission to obtain and share confidential
information about me and my household, providing it is needed to investigate and assess my housing
situation. I acknowledge that I am not making a homeless application by agreeing to this referral being
made. I declare that all of the information given is true and correct in all respects. I have read the privacy
notice and understand how my data will be processed
Signature……………………………………………… Date……………………………………………………
NOTE: The person being referred must give consent to the referral.
Please send this Referral form by email to the relevant Council as below:
dutytorefer@adur.gov.uk
dutytorefer@arun.gov.uk
dutytorefer@chichester.gov.uk
dutytorefer@crawley.gov.uk
dutytorefer@midsussex.gov.uk
dutytorefer@worthing.gov.uk
You will receive an acknowledgement within 48 hours.
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DUTY TO REFER FORM Date of referral (Mid Sussex District Council)

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Completed 31 July 2020

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