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Sections marked with * are Mandatory
SECTION 1 - REFERRAL AGENCY DETAILS
SECTION 2 - APPLICANT DETAILS
SECTION 3 - PREVIOUS ADDRESS HISTORY (INCLUDING SUPPORTED ACCOMMODATION)
Address
Dates / Duration
Type of Occupancy, i.e. Private, Supported
Reason for Leaving, i.e. Arrears, ASB
SECTION 4 - APPLICANT MEDICAL BACKGROUND / HISTORY
SECTION 1 – REFERRAL AGENCY DETAILS
Address
SECTION 5 - SUPPORT GROUP / SUPPORT NEEDS
Support Group Y/N
Support Needs: Please Provide Details of Level and Type of Support Required
SECTION 6 - AUTHORISATION - APPLICANT
  • I give my consent to the disclosure of this information for the purpose of finding accommodation and to the disclosure of any supplementary information attached for housing purposes.
  • I give my permission for the outcome of this referral to be explained to the referral agency
  • I agree to participate in a support package including support planning and assessment
SECTION 7 - AUTHORISATION REFERRAL AGENCY
SECTION 7 - SUPPORTING DOCUMENTATION / ADDITIONAL INFORMATION
PLEASE NOTE: SUCCOUR HAVEN CIC IS AN EQUAL OPPORTUNITIES HOUSING PROVIDER.
HOWEVER WE RESERVE THE RIGHT TO REFUSE REFERRALS WITH A HISTORY OF ARSON (INSURANCE REGULATIONS) AND SEX OFFENCES
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Succour Haven CIC

Succour Haven CIC is passionately committed to equity and equal opportunity, focusing on assisting our service users irrespective of colour, gender, or personal circumstances. Our housing services include mental health challenges, substance abuse and domestic violence.

Contact Info

74 Station Road, Birmingham, B23 6UG

info@succourhaven.org

 

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© 2024 Succour Haven CIC. All rights reserved. Registered in the UK. Registered office address 74 Station Road, Erdington, Birmingham, England, B23 6UG. Company Number 13807267