Assessment of Needs

Referral Form /
Needs Assessment

Please answer all relevant questions

Date of birth:

NI   no:
Next of Kin:

Address: Address of next of kin:

Postcode: Postcode:

Contact Tel No: Tel No:



Marital Status:

Country of Origin

Immigration status

Accommodation status

Where are you staying now

Are you getting support
In your current/previous accommodation
Have you approached the
council for housing

Income information
Provide information about
any income or savings you

                                                  Benefits Information
Type of benefit in receipt of In process of claiming Already claiming /
evidence seen
Income Support
Incapacity Benefit
Job Seekers Allowance
Housing/Council Tax Benefit
Employment Support Allowance
DLA Mobility Component
DLA Care Component
Any other benefit (please outline)

Housing Need (staying safe)

Is your current accommodation temporary?                       Is this due to end soon?

Are there rent arrears?

Has an eviction order been issued? Date of Eviction?

Finance and Benefits (economic wellbeing)

Are there issues with accessing benefits?                         Are there any debt problems?

Education, Training and Employment (enjoy and achieve)

Do you speak and write English?                  

Have you worked and trained in your country of origin?    

Health (be healthy)

Physical Health and Medicine?

Mental Health and Medicine?

Cultural Integration and social Inclusion (make a positive contribution)

Legal issues including immigration assistance (get the right advice)

I have read the information above and I can verify that the information is true to my knowledge

Person Referring...