Referral Application Form

If email delivery fails, we try to keep a private copy of your enquiry so our team can follow up. How we use your information.

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Required fields completed

01About you

Your name and the best ways to contact you.

Name (required)

First Name

Last Name

Date of birth (DD/MM/YYYY) (required)

Contact Number

Sex at birth (required)

02Where you live

Tell us about your current and previous addresses.

Current Address (required)

Street Number / Street Name / City / Postcode

Previous Addresses

Please enter your full previous addresses including the street number, street name, city and postcode. Please also state which Housing Association or provider you were with and the duration of the accommodation.

03Your background & access needs

Help us understand you and any adjustments or support you may need.

Ethnicity (required)

Your Religion/Beliefs (required)

Sexual Orientation (required)

If you have any disabilities (physical i.e. health condition) or mental health illness, please let us know below

Disabilities can include physical or mental impairment as well as a long-term health condition.

If you have any additional communications needs, please let us know below.

This could be things such as Braille, Large Print, Audio-tape, Translation services / British Sign Language or Makaton Sign language

04Benefits & finances

Information about your National Insurance number and benefits.

National Insurance Number (required)

Current Benefits (required)

If you are on benefits, please state which date these benefits started on (DD/MM/YYYY)

05Your support needs

Tell us about existing support and any health or substance-related needs.

Do you have a worker assigned to you? (required)

Please select which of the following workers are assigned to you. This could be a social worker, support worker, mental health support or drug support worker.

Social Worker Support Worker Mental Health Support Drug Support Worker Probation Officer I do not have an assigned worker

If you do have an assigned worker, please can you provide their name, phone number and email address

Do you suffer from a mental health illness? (required)

If you answered yes to having a mental health illness, please kindly explain in more detail below

Do you have drug related problems? (required)

If you answered yes to drug-related problems, please explain in more detail below

06Your circumstances

Information that helps us assess your accommodation and support needs.

Do you have any criminal offences or convictions? (required)

If you have been convicted of a criminal offence or have pending court appearances, please give the details below.

Please include the nature of offence, the dates of the offence or dates of the court appearance. Please note that the declaration of any criminal offences will not necessarily mean that you will be excluded from being offered housing related support.

Are you homeless? (required)

If you answered yes to being homeless, please explain why below

08Review & consent

Please review your answers and read the statements below before submitting.

I acknowledge that I have read the terms, conditions and criteria in the referral application guide (required)

Yes

I give my full consent to Aspect Housing to use the information I have provided in this application form and understand it will only be used by Aspect Housing for the purpose of providing their support services. (required)

Yes

Read our privacy policy for how we use your information.

Tell us about the support you need.