Self-Referral Form

Women's Supported Accommodation

Thank you for your interest in Safe Haven.

Before You Begin

This form is for women who wish to refer themselves for supported accommodation.

Please complete this form as fully as possible.
Completing this form does not guarantee accommodation.
All applications are subject to eligibility, safeguarding, risk assessment and room availability.
Any information you provide will be treated confidentially and handled in accordance with UK data protection legislation.
The information you provide helps us understand your circumstances and determine whether our accommodation and support services are suitable for your needs.

If you are in immediate danger or require emergency assistance, please call 999.

Referrer Full Name

Date of Birth

Mobile Number

Email Address

Current Address

National Insurance Number

Which best describes your current housing situation?

Do you have somewhere safe to stay tonight?

Yes No

When do you need accommodation?

Please tick all that apply.

I am aged 18 or over. I require women-only accommodation. I am willing to engage with support while living at Safe Haven. I understand that house rules must be followed.

Do you have any medical conditions we should be aware of?

Yes No

If yes, please give brief details:

Do you have any mobility needs or disabilities?

Yes No

If yes, please give brief details:

Do you have any allergies we should know about?

Yes No

If yes, please give brief details:

Do you currently feel safe?

Yes No

Are you fleeing domestic abuse?

Yes No

Is anyone currently placing you at risk?

Yes No

Are there any risks we should know about to help keep you and others safe?

Yes No

If yes, please briefly explain

Are you currently receiving support from another organisation?

Yes No

If yes, please tell us who

Please tell us anything else you feel would help us understand your situation.

Please tick each box.

I confirm the information I have provided is true to the best of my knowledge.

I understand that submitting this form does not guarantee accommodation.

I consent to Safe Haven processing my personal information for the purpose of assessing my application.

I agree that Safe Haven may contact me regarding my application.

Applicant Name

Date

Self-Referral Form

Women's Supported Accommodation

Before You Begin

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