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Fill in the form below just as you would on paper — type in the boxes, tick the boxes that apply and sign where asked — then press Submit referral at the bottom.

REAI Housing | Referral / Initial Assessment Form

REAI Housing

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Referral / Initial Assessment

Stage 1 – Placement Assessment

In order to access this Exempt Accommodation Service, the applicant must have a qualifying level of support needs during the assessment process. It is important to understand the criteria for support is met under the DWP legislation. The applicant’s willingness to participate in the support is crucial; failing which the Accommodation cannot be offered.

We cannot house registered sex offenders, convicted arsonists or children unless you have a specific licence to do so. If a room is not granted, please keep this form on record as evidence of these checks.

Date of Assessment
Name of person undertaking Assessment
Preferred Area
Telephone number
Organisationor “Self-referral”
Personal details of applicant
Preferred Title:
Surname:
First Name(s):
Other Name(s) Known as:
Date of Birth:
Place of Birth:
Address (where have you been living/staying previously):
Postcode:
National Insurance No:
Home No:
Mobile Tel No:
Work No:
Gender:
Marital Status:
Current Situation / Reason for Homelessness:
Diversity monitoring form
Ethnic origin
If Other, please specify:
Religion
Any other – please specify:
Sexual orientation
Communication needs – Are any of the following needed?
If yes, please provide more details:
Financial information
What is your source of income / benefits?
Total Amount Received:
How Often:
Do you have any debts? If so, please provide details:
Do you have any issues with gambling? If so, please provide details:
Criminal record
Have you ever been convicted of a criminal offence or have any pending court appearances? If yes, please give details below:
Nature of Offence
Date
Sentence

PLEASE NOTE: the declaration of criminal offence(s) does not necessarily mean that you will be excluded from being offered a housing related support package.

Declarations

I agree that the information contained in this referral/initial assessment form is true and accurate and I consent to it being used as part of the assessment and risk process. By signing below, I agree that all the information provided is true and I will inform the provider of any changes. I also understand that the provider has the right to refuse support if I have provided any information that is incorrect/false.

Signature:

Sign here

Date: 05/11/2026

INFORMATION SHARING

I understand that the provider will carry out checks on the information I have provided through contact with other agencies, e.g. Medical Professionals, probation services, social services etc. I am signing to say I give permission to share information about me with other agencies.

Signature:

Sign here

Date: 05/11/2026

The office boxes below are completed by REAI Housing. Please carry on to the confirmation at the end.

Office use only
Date referral received
Referred from (agency name or self-referral)
Are the criteria met? (must have at least 5 support needs to qualify)
If placement not awarded, please state reasons below.
Upon receipt of this referral form, the support worker must confirm all information in this document with the tenant to check for any updates/changes and to ensure the risk assessment and support plan are accurate.
Full check completed with the tenant?
If no, please state why:
Support worker name:
Support worker signature:
Date:
I confirm that all the information provided in this referral is true to my knowledge.

Client Signature:

Sign here

Client Print Name:

Support Worker / Assessor Signature:

Sign here

Support Worker / Assessor Print Name:

Date:

Confidential – For official use only

Boxes marked * are required. The form is sent securely and only seen by the REAI Housing team — privacy policy.