Email address How would you prefer to be Phone Email Letter Other, please state contacted? Relationship to you Next of kin name and contact details (to be contacted in case of emergency) Reason for application Are you or have you ever had any support from Social Yes No Services (Social Care)? Are you a care leaver? Yes No Are you on a child protection plan? Yes No EQUAL OPPORTUNITIES MONITORING Gender Male Female Transgender? Yes No Don’t Know Sexuality Religion Nationality Preferred language If preferred language not English (please comment whether able to communicate in English at all) Asian or Asian British - Bangladeshi Gypsy, Romany, Irish Traveller Asian or Asian British - Indian Mixed - White & Asian Asian or Asian British - Pakistani Mixed - White & Black African Asian Other Mixed - White & Black Caribbean Black or Black British - African Mixed - Other Black or Black British - Caribbean White British Black or Black British - Other White Irish Chinese / Other Ethnic Group White Other Housing Lodger Council/housing association rented Living with family and friends Owner occupier/shared owner What sort of (if you are living with a Sanctuary tenant Temporary accommodation accommodation please give details below) are you in at the Supported housing Prison/offenders institution moment? No fixed abode Other type of accommodation Private landlord (give details below) Details If you are currently in prison/offenders institution, when will you be released? Are you currently homeless? If yes, please give details Yes No and state how long you have been homeless for
Email address How would you prefer to be contacted? Phone Email Letter Other, please state Next of kin name and contact details (to be contacted in case of emergency) Relationship to you Reason for application Are you or have you ever had any support from Social Services (Social Care)? Yes No Are you a care leaver? Yes No Are you on a child protection plan? Yes No EQUAL OPPORTUNITIES MONITORING Gender Male Female Transgender? Yes No Don’t Know Sexuality Religion Nationality Preferred language If preferred language not English (please comment whether able to communicate in English at all) Asian or Asian British - Bangladeshi Gypsy, Romany, Irish Traveller Asian or Asian British - Indian Mixed - White & Asian Asian or Asian British - Pakistani Mixed - White & Black African Asian Other Mixed - White & Black Caribbean Black or Black British - African Mixed - Other Black or Black British - Caribbean White British Black or Black British - Other White Irish Chinese / Other Ethnic Group White Other Housing What sort of accommodation are you in at the moment? Council/housing association rented Owner occupier/shared owner Temporary accommodation Supported housing No fixed abode Private landlord Lodger Living with family and friends (if you are living with a Sanctuary tenant please give details below) Prison/offenders institution Other type of accommodation (give details below) Details If you are currently in prison/offenders institution, when will you be released? Are you currently homeless? If yes, please give details and state how long you have been homeless for Yes No
Supported-Living-Mental-Health-Referral-Form-2.docx