Are you in Income ESA JSA DLA Pension Housing Other receipt of any Support Benefit benefits or income? £…………. £…………. £…………. £…………. £…………. £…………. £…………. (weekly, fortnightly, W/F/M W/F/M W/F/M W/F/M W/F/M W/F/M W/F/M monthly) Location of Date of Benefits Office Last Payment Priority Debt Outstanding to: Amount: Paid into: Post Office Bank Other Account £…………… Non- Outstanding to: Amount: Do you have any Priority Debt difficulties £…………… relating to money management? SECTION TWO HOUSING SITUATION – What is the Service User’s current housing situation? Please select from the options below; Sofa surfing Rough Sleeping Problems with current Threatened with homelessness Housing Association – with friends or accommodation e.g. e.g. asked to leave home, notice Tenant relatives disrepair, rent issues served by landlord Local Authority Living in Living in emergency Private rented tenant Owner occupier tenant supported accommodation e.g. accommodation hostel/refuge Leaving prison Leaving Hospital Temporary Living in approved premises Fleeing (detail date of /residential care accommodation (Bail Hostel) violence/safety release) (detail discharge provided by LA issues date) Other Registered YES NO (Please elaborate) with the NIHE Accommodation History (Last Five Years if Possible) Date from Date to Type & Location of Reason for Leaving i.e. eviction, Accommodation family breakdown, discharge etc SECTION THREE SUPPORT REQUIRED – Please indicate below if what level of support the applicant LOW MEDIUM HIGH would require in the following areas; Developing budgeting skills Managing debt Support to access/claim welfare benefits Developing skills to complete Developing skills to undertake domestic/household tasks Basic skills (numeracry/literacy) Accessing further education Opportunities for paid employment Accessing community, social, leisure activities Accessing faith and cultural networks
Are you in receipt of any benefits or income? (weekly, fortnightly, monthly) Income Support £…………. W/F/M ESA £…………. W/F/M JSA £…………. W/F/M DLA £…………. W/F/M Pension £…………. W/F/M Housing Benefit £…………. W/F/M Other £…………. W/F/M Location of Benefits Office Date of Last Payment Priority Debt Outstanding to: Amount: £…………… Paid into: Post Office Bank Account Other Non- Priority Debt Outstanding to: Amount: £…………… Do you have any difficulties relating to money management? SECTION TWO – HOUSING SITUATION What is the Service User’s current housing situation? Please select from the options below; Sofa surfing – with friends or relatives Rough Sleeping Problems with current accommodation e.g. disrepair, rent issues Threatened with homelessness e.g. asked to leave home, notice served by landlord Housing Association Tenant Local Authority tenant Living in supported accommodation Living in emergency accommodation e.g. hostel/refuge Private rented tenant Owner occupier Leaving prison (detail date of release) Leaving Hospital /residential care (detail discharge date) Temporary accommodation provided by LA Living in approved premises (Bail Hostel) Fleeing violence/safety issues Other (Please elaborate) Registered with the NIHE YES NO Accommodation History (Last Five Years if Possible) Date from Date to Type & Location of Accommodation Reason for Leaving i.e. eviction, family breakdown, discharge etc SECTION THREE – SUPPORT REQUIRED Please indicate below if what level of support the applicant would require in the following areas; LOW MEDIUM HIGH Developing budgeting skills Managing debt Support to access/claim welfare benefits Developing skills to complete Developing skills to undertake domestic/household tasks Basic skills (numeracry/literacy) Accessing further education Opportunities for paid employment Accessing community, social, leisure activities Accessing faith and cultural networks
NWMMREFERRALFORM080316.docx