Housing Advice Referral Form

Client details: please complete the details of the person with the Spinal Cord Injury who requires Housing Advice

First name (required)

Last name (required)

Telephone number (required)

Email address (required)

Age bracket (required)

Local Authority (required)

Does the person being referred have a Spinal Cord Injury (SCI)? (required)

Injury Level (e.g. T5 Complete) (required)

Is this a self-referral or a referral from a professional? (required)

Details of Person Completing Form (if different from above)

If you are not the person with a spinal cord injury and are making a referral or seeking advice on their behalf, please complete your details below.

I confirm that I have permission from the named party above to share their details with Aspire (required)

Name of person making referral

Contact number of person making referral

Email address of person making referral

Relationship to person named above (with a SCI) e.g. spouse, parent, friend

Job title & organisation (if applicable)

Who should we liaise with? e.g. person with SCI/ person who made the referral etc.

Preference for Call (required)

Reason for Referral (required)

Advice on housing optionsPurchase suitable propertyAccess council housing registerAdvice on moving areaMove to suitable social housingAdvice/assistance with adaptationsObtain suitable private rentOther - please let us know below

Other

What is the Current Tenure? (required)

Private rentSocial HousingHome Ownership - Owned OutrightHome Ownership - MortgagedHomelessUnsure

Please give some background to the current situation e.g. background of housing issues to date, current residence, other known medical conditions, exacerbating circumstances etc (required)

I am happy to receive further information from Aspire (required)

I am happy for my details to be shared with Back Up