Emergency Accommodation Referral

Online Referral

Please complete the form below to submit a client referral for emergency night-by-night accommodation.

Maninplace is unable to guarantee a bedspace will be available at the point of referral, unless prior arrangements have been agreed with our team. We aim to respond to referrals within 3 hours, but this may be extended if our housing officers are responding to the needs of others. If you have not received a response from us after 3 hours, please call us on: 01952 248248 and ask to be transferred to the “Homelessness Team”.

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Step 1 of 5

Some of the questions needed to complete this referral may be of a sensitive nature to your client. Please take all necessary steps to offer a safe and secure environment to discuss the details required and ensure your client is aware that their answers will not determine the outcome of the referral.

To enable the referral to be assessed, all sections must be completed.

DATA PRIVACY

Consent to share information.

In order for us to process the referral, we need to be able to share information about your client with partners and agencies who provide applicable support services.

All details obtained within the referral will be held securely and confidentially by Maninplace. However, we may need to share some of your client’s details in order to access additional support services from partners and agencies. Where it is necessary to share information, we will only share data that is relevant, and only with those who will provide services to your client.

I have obtained my client's consent to the gathering and storage of their personal data on this website, for the purposes of completing a referral for emergency accommodation.

You must have your client’s consent to provide their information for this referral. If you do not have their consent, you may only share their personal data to protect their vital interests, as defined in the ‘Data Protection Act 2018’ and the ‘GDPR’. If you do not have consent, but you believe you have a legitimate reason to submit information for a referral, please contact us to discuss this further.

Save and Resume Later

	Not applicable	Low	Medium	High
Alcohol use	Not applicableAlcohol use Not applicable	LowAlcohol use Low	MediumAlcohol use Medium	HighAlcohol use High
Drug use	Not applicableDrug use Not applicable	LowDrug use Low	MediumDrug use Medium	HighDrug use High

	Not applicable	Low	Medium	High
Risk to self	Not applicableRisk to self Not applicable	LowRisk to self Low	MediumRisk to self Medium	HighRisk to self High
Risk to the public	Not applicableRisk to the public Not applicable	LowRisk to the public Low	MediumRisk to the public Medium	HighRisk to the public High
Risk to staff	Not applicableRisk to staff Not applicable	LowRisk to staff Low	MediumRisk to staff Medium	HighRisk to staff High
Risk to other residents	Not applicableRisk to other residents Not applicable	LowRisk to other residents Low	MediumRisk to other residents Medium	HighRisk to other residents High
Risk to particular person(s)	Not applicableRisk to particular person(s) Not applicable	LowRisk to particular person(s) Low	MediumRisk to particular person(s) Medium	HighRisk to particular person(s) High
Risk from themself	Not applicableRisk from themself Not applicable	LowRisk from themself Low	MediumRisk from themself Medium	HighRisk from themself High
Risk to Children	Not applicableRisk to Children Not applicable	LowRisk to Children Low	MediumRisk to Children Medium	HighRisk to Children High
Risk of re-offending	Not applicableRisk of re-offending Not applicable	LowRisk of re-offending Low	MediumRisk of re-offending Medium	HighRisk of re-offending High

Emergency Accommodation Referral

Online Referral

DATA PRIVACY

Consent to share information.

If your client has not provided you with consent to share their information with Maninplace, please obtain consent before continuing with this form.

EXIT FORM

If your client has not provided you with consent for Maninplace to share their information with relevant agencies and services applicable to the application, please obtain consent before continuing with this form.

EXIT FORM

REFERRER DETAILS

CLIENT'S PERSONAL DETAILS

CUSTOMER CIRCUMSTANCES

ACCOMMODATION HISTORY

Current landlord

FINANCE & BENEFITS

RISK ASSESSMENT

Offending and Criminal Convictions

Criminal convictions details

RISK RATING – OFFENDING

Substance Misuse

Details of substances used

RISK RATING – SUBSTANCE USE

Mental Health Conditions

Medication Details

RISK RATING – MENTAL HEALTH

Physical Health / wellbeing / Disability

Medication Details

RISK RATING – PHYSICAL HEALTH

OVERALL RISK INDICATORS

Your Support Matters!

Online Referral

DATA PRIVACY

Consent to share information.

If your client has not provided you with consent to share their information with Maninplace, please obtain consent before continuing with this form.

EXIT FORM

If your client has not provided you with consent for Maninplace to share their information with relevant agencies and services applicable to the application, please obtain consent before continuing with this form.

EXIT FORM

REFERRER DETAILS

CLIENT'S PERSONAL DETAILS

CUSTOMER CIRCUMSTANCES

ACCOMMODATION HISTORY

Current landlord

FINANCE & BENEFITS

RISK ASSESSMENT

Offending and Criminal Convictions

Criminal convictions details

RISK RATING – OFFENDING

Substance Misuse

Details of substances used

RISK RATING – SUBSTANCE USE

Mental Health Conditions

Medication Details

RISK RATING – MENTAL HEALTH

Physical Health / wellbeing / Disability

Medication Details

RISK RATING – PHYSICAL HEALTH

OVERALL RISK INDICATORS