Wiltshire Council | Housing Options E-Form

Housing Options E-Form

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If you need to refer a customer who is homeless or threatened with homelessness within the next 56 days please complete the e-form below. Please ensure that you include as much detail as possible. Once the form has been reviewed by the Housing Options team someone will be in contact with you and the customer to discuss the referral further.

Your details (Referrer)

What is your name : *

What organisation do you work for ? *

Your telephone number : *

Your email address : *

Customer Details

Customers name : *

Date of birth : *

Telephone number : *

Email address : *

Please tell us the customers current or previous address (if already homeless)

Address 1 : *

Address 2 : *

Address 3 :

Address 4 :

Postcode : *

Other Details

Why do you think this customer is homeless or likely to be homeless within 56 days?

Reason : *

What professionals are the customer currently working with? Please include name and contact details, if applicable*

(i.e. Police, Probation, Hospital, Mental Health Team, Adult Social Care, Children’s Support and Safeguarding, Wiltshire Substance Misuse Service)

Who is the customer working with ?

Details of customer’s needs, if applicable (i.e. mental health diagnosis, medical conditions, mobility issues, substance misuse issues)

Details of the customers needs

Has the customer given you permission to refer their case to Wiltshire Council ?

Has the customer given you permission ? *

Does the customer consent for Housing Options to conduct enquires into their referral ?

Consent given ? *

Have you shown the customer Wiltshire Council’s Housing Subject Information Notice? *

Does the customer know how Housing Options will process the information provided?

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Housing Options E-Form

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