Housing advice and support form

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**WE ARE CURRENTLY ONLY OPEN FOR HOUSING REFERRALS FOR 16-25 YEAR OLDS IN NORTHFIELD**

This form is for both professionals and people making a self referral.

Section/Page 1 is for professionals and agencies making a referral on behalf of someone they are currently supporting. The person you are referring must be aware and give permission for you to make this referral on their behalf.

Self referrals - If you are completing this form for yourself, please input your email address below and then skip to section/page 2.

Unfortunately if your enquiry is regarding a repair issue we are unable to help, we advise you to call 03445151800

Email *

We are currently working with the following people, please confirm which criteria you meet: *

Aged 16-25 in Northfield in need of housing advice

Required

If you are making this referral for someone else please provide your name *

If you do not meet our criteria and are in need of assistance, please contact the agencies below (if in immediate danger please call 999):

Birmingham City Council 0121 303 2296

Sifa 0121 766 1700

St Basils (16-25 years Old) 0300 303 0099

Domestic Abuse Homeless Hub 0121 272 8905

Trident Domestic Abuse helpline 0800 411 4223

Birmingham and Solihull Women's Aid 0808 800 0028

Organisation or relationship to person being referred

Contact Number

Please indicate what work you are doing with the person you are referring and what support you are providing.

Please detail any information that we may need to know such as risks, special assistance requirements etc

Please tick to confirm that you have permission to make this referral. Please note we do not provide updates on progress of the referral particularly without the explicit consent from the person being referred.

I have permission to make this referral

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