ONLINE REFERRALS

This form should only be used if you are an agency making a referral on behalf of a single homeless male client only. For all other clients please visit our Downloads Page or call 020 7473 5286.

Please note:

• All single mail clients referred to Just Homes must be eligible to receive UK benefits
• Just Homes accepts agency-referrals only (no self-referrals)
• We will always take steps to check the authenticity of online referrals

Section 1: Referring Agency
Agency Name:
Contact Name:
Address:
Town/City:
County:
Postcode:
Phone Number:
Fax Number:
Email Address:
Section 2: Client's Details
First Name:
Middle Name:
Surname:
Prefers to be known as:
First Language:
Date of Birth:
NI Number:
Phone Number (if available):
Email Address (if available):
Section 3: Further Details
Please answer all questions below, providing additional information where requested:
Please give details of the client's current housing situation:
Does the client have a Newham connection?		Yes    No
Does the client have any physical or mental problems?		Yes    No
If 'Yes' please give details:
Has the client ever been convicted of an offence?		Yes    No
If 'Yes' please give details:
Is the client currently on probation?		Yes    No
Is the client eligible to claim UK benefits?		Yes    No
Is the client currently claiming any benefits?		Yes    No
If 'Yes' please give details:
Has the client left any previous accommodation in any of the following circumstances?
Because they owed rent to the landlord:		Yes    No
Because they were the subject of complaints by neighbours and/or were in dispute with neighbours:		Yes    No
Because they racially harrassed others:		Yes    No
Because they committed arson or other damage to the property:		Yes    No
Because they were violent towards others:		Yes    No
Because they were engaged in antsocial behaviour, including noise or drug related issues:
Does the client need help with literacy skills?		Yes    No
Does the client need help with numeracy skills?		Yes    No
Was the client's spoken English sufficient to be able to easily provide the information required on this form?		Yes    No
Does the client have a history of substance abuse?		Yes    No
If 'Yes' please give details:
If the client is currently in employment please give details of their job, their employer's name, address and telephone number, and contact person's details:
Section 4: Any Other Information
Please give any other information relevant to your client's application not already covered in this form:
Section 5: Form Submission
Before pressing 'Send' please read and affirm the following statements:
This form has been completed in the presence of the client and they have been shown the completed form.		Yes
The client agrees that the information is correct. They also understand that, by failing to disclose information, or by making false statements, they may be liable to lose their accommodation in the future.		Yes
The client agrees that the information may be shared between the referral agency and Just Homes.		Yes
The information given on this form is confidential to Just Homes' staff and complies with the Data Protection Act 1984.
Just Homes operates an 'open files' policy; this form and any documents relating to this form can be shown to the client, subject to third party disclosure.
If called for interview, the client will need to provide supporting documents as may be required by Just Homes.