RREFERRAL FORM
Reference Number
(office use only):
Date of referral:
Making Moves Hub, Ballymena is a project that brings together a number of local organisations,
under the same roof (Housing Executive District Office Mount Street, Ballymena), at the same time
(every Thursday 1pm-2pm), to provide early intervention, prevention and support you with issues,
which may or has resulted in homelessness.
By ticking the Data Protection box you acknowledge you have read the statement provided
Please fill in the following information to help us understand what support you need.
Name: ___________________________________________________________________________
Gender:
Male
Female
Ethnicity:
White
Chinese
Irish traveller
Indian
Pakistani
Mixed ethnicity
Asian
Black
Other
Are you involved with the criminal justice system?
Yes
No
Please note that your answer to the above will not exclude you from accessing the services
available through the Making Moves Hub.
Current/contact address: ____________________________________________________________
___________________________________________
Date of birth: ________________________
Postcode: ________________________
National Insurance No: ____________________
Contact No: _______________________________________________________________________
Email: ____________________________________________________________________________
Do you suffer from any mental health problems?
YES
NO
Do you suffer from any physical health problems?
YES
NO
Where are you currently staying?
Hostel
Owner occupier
Supported Housing
Rented
Sleeping rough
Staying with friends/family
Other: ___________________________________________
If you have made a housing application to the Housing Executive please provide the following:
Housing reference number: __________________________________________________________
District Office applied to: ____________________________________________________________
What are the current issues that you would like advice and support with?
Education & Training
Financial Advice
Employment
Drug and/or alcohol harm reduction
Health & wellbeing
Emergency food and/or clothing
Benefits
Community support
Tenancy support
Housing
Mental Health
Debt Advice
Other: ____________________________________________________
Please tell us which organisations, if any, that you are currently getting help from?
__________________________________________________________________________________
Where did you hear of Making Moves? _________________________________________________
The Making Moves Hub is a collaboration between a number of organisations, are you happy for
these organisations to share information they hold about you?
Yes
No
Signature: ________________________________________
Date: ________________________
__________________________________________________________________________________
Referral Agent
Name: ___________________________________________________________________________
Organisation: _____________________________________________________________________
Tel. No: __________________________________________________________________________
Email: ____________________________________________________________________________
Please email your completed referral form to:
[email protected]
If unable to email, please contact Geraldine Wills
(email: [email protected] or tel: 0744 250 2611) to make arrangements for this
completed form to be picked up from your office/place of work.