Applicants and referrals

If you wish to apply then please complete the form below

If you wish to apply for our services then please contact us by completing the form below:

Name *

First

Last

Phone Number *

Email *

Gender *

Ethnic Origin *

Place of Birth *

Current Full Address *

Current Postcode *

National Insurance Number *

Preferred Area *

Please select up to 5

Sexual Preference *

Martial Status *

Religion *

Communication Needs *

Are you currently pregnant? *

Name Of Next Of Kin *

What Is The Full Address Of Your Next Of Gin? *

What is your relationship with your Next of Kin? *

Next of Kins Phone Number *

What is your current living situation? *

Why do you want to move from your current accommodation? *

What was the last address you claimed Housing Benefit from? *

When did that Housing Benefit start? *

Are you on the Birmingham City Council waiting list for housing? If yes, how long? *

How long have you been living in Birmingham?

Years

Do you have any debts? If so, please provide details *

Please state all criminal convictions (if any) including dates and time served *

Do you have any S1 or Arson offences? (Please provide as much detail as possible) *

If you are on probation, please state the officer's details and when the order ends *

Do you have any alcohol or drug uses (past or present)? If so, please detail how often and which drugs *

Do you have any mental health issues? *

Do you have any physical health issues? *

Are you currently on any medication? If so please provide details *

Do you have any issues with gambling? If so please provide details *

Do you have any other conditions you think you have to make us aware of? *

Do you have contact with any other external support teams? *

Are you engaging with support and/or willing to cooperate further with our support services? *

Please tick all the areas of support that you feel apply to you *

Please note this is supported housing and if you have no support needs, unfortunately, we won't be able to house you

Have you ever served in the British Armed Forces? If yes, have you ever been injured/disabled from doing so? *

How would you describe your status? *

What benefits do you receive? *

How much are you receiving and how often? *

When is your next payment due? *

What is the name and or location of your benefit office? *

Please note, there is a service charge of £17 per week to stay at a Life Transitions Accommodation, we ask that this be paid 4 weeks in advance. This would mean that we would require £70 on the day you move in *

Lastly, do you have proof of benefits? *

If Yes, please send via email to info@

New resident referral form

01

Submit form

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02

Application review

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03

Discuss options

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04

Secure accom.

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Required resident documents

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