online referal

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:

Referral Agency 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):

Client 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?

Does the client have any physical or mental problems?

If 'Yes' please give details: