Housing Coordination Referral Form

Name(Required)
DD slash MM slash YYYY
Address

HOUSING CRITERIA

1. Applicant must have a medical mental health diagnosis.(Required)
2. Applicant must be supported by a secondary service.(Required)
3. Applicant is registered with Social Housing (MSD).(Required)

DO YOU HAVE ANY DEPENDANTS?

Children or Ward under 18yrs in your care
Name
Date of Birth
 

NEXT OF KIN

Family/ Friends/ other – in case of an emergencies(Required)
Name
Contact Number
Address
 

OTHER COMMUNITY SERVICES

(other services that are supporting you in anyway, AOD/OT)
OTHER COMMUNITY SERVICES
Name
Organisation
Contact Number
Email
 

HOUSING INFORMATION:

HOUSING NEEDS

What Renting option best suits your needs?(Required)

Do you smoke cigarettes or vape?(Required)
Do you own any pets?

TENANCY REFERENCE

From a previous Landlord or character references from a person of good standing that has known you for 12 months or more.
TENANCY REFERENCE(Required)
Reference name
Phone number
 
Drop files here or
Accepted file types: pdf, jpg, png, Max. file size: 2 MB, Max. files: 5.
    Client Consent(Required)