Housing Advice Referral Form

I can confirm that I have the consent of the individual to make this referral to the Waltham Forest Community Hub. The individual gives their consent to Waltham Forest Community Hub to share sensitive personal information with limited partners. NOTE: Data will only be shared with specific partners following discussion with the individual (e.g. if we are referring you to another service) and will never be shared for marketing purposes without confirming with the individual first). The individual also gives consent to Waltham Forest Community Hub recording sensitive personal information about them.

Personal Details

Full Name

Address & Post code

Main Phone Number

Email Address

Main Language

Gender

Date of Birth * required

Ethnicity

How many people, including yourself, live in your household? (do not include external persons in shared accomodation. * Required

Live alone

Live with partner

live with 1 child

live with 2 children

Live with 3 or more children

Living with parents

Live with other family members

Live with any other person

Other (specify in housing circumstance below)

Accommodation Status (if known)

Do you have any specific needs? (Tick all that apply) * Required

None

Deaf or hard of hearing

Vision impairment

Other physical disability

Learning disability

Mental health condition

Allergies

Other

Main Housing Issue

Description - Please briefly describe your current housing situation and Include any risks involved (e.g Violence, unwanted visitors, leaks etc....)

Upload File

Upload supported file (Max 15MB)

REFERRER DETAILS

Name of Person Making Referral

Job Title

Referrer Organisation

Email of Person Making Referral

Thank you for submitting your registration!

Contact OUR CHARITY

18A Orford Road
London E17 9LN

020 8223 0707
info@wfchub.org

Connect with us

Registered Charity Number : 1118523 // Company no. 5642169

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