Make a referral for supported living | Zetetick housing

Referral Lead Form

Due to our Charity Objects and specialism in tenants that require enduring support to live within the local community, we require a health/social care professional to complete our referral documentation.

    Details of Referrer
    1. Please complete as much of the form as possible with as much information available. Note: * denotes mandatory responses.

    2. Applicants Details

    Click 'NEXT' to go to the next section of the referral form - Thank you for your cooperation.

    Applicants Representative
    1. Name

    2. Guest Name

      1. FlatHouseShared House
      2. FlatHouseShared House
      3. FlatHouseShared House

    Click Next to go to the next page of the referral form - Thank you for your cooperation

    Support Provider & Funding
    1. Whilst Zetetick is a Charity, ALL nominations MUST be supported under contract with the Local Authority, either direct support with Zetetick Housing or by their approved nominated Care Provider for and on behalf of Zetetick Housing.

      1. -----------

        1. YesNo
        2. Please provide a brief history on any prior tenancy arrangements and/or issues i.e. arrears, ASB, other legal actions etc

        Click Next to go to the next page of the referral form - Thank you for your cooperation

        Type of Accommodation Required
        1. This Section must be completed

        2. There may be issues that the applicant feels has contributed to them needing support and/or new accommodation. Please state whether they are affected by any of these areas of support need?

        3. Area of Support Need

          1. UnemploymentMental Health issuesEx-OffenderArrears/DebtSensory ImpairmentAlcoholLearning DisabilityPhysical healthImpairmentDrug UseOther vulnerability
          2. YesNo
        4. YesNo
        5. YesNo
        6. Consent for GDPR

        Thank you for completing the referral form, if you have filled all the mandatory sections, please click on submit to send the form to Zetetick housing.

        Referral Form in Word

        If you prefer you can download the form in word fill it in and email it to us

        Author

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