Housing & Welfare Benefits Referral

Please complete this form so we can understand your issue and arrange the right help.

If you need help using this form or would prefer to speak to someone directly, you can contact Accommodation Concern on 01536 416560 or by email at help@a-c.org.uk.

Who is completing this form? I am completing this form on behalf of someone else (for example, as a support worker, caseworker or other professional).

Please give your own details as the person making this referral. The rest of the form should be filled in with the details of the person you are referring.

Your name Your organisation (optional) Your email address Your contact number Please give us at least one way to contact you — an email address or a phone number.

About you Title First name Surname Date of birth Address Postcode

Contact details Home phone (optional) Mobile phone Email address

Referral details What do you need help with? Where do you live or need help?

Welfare benefits issue Which benefit do you need help with? What type of help do you need? Is there a deadline or recent decision?

Is this causing immediate hardship?

No money for essentials Rent shortfall or arrears Risk of eviction Food or fuel crisis No immediate hardship Other

Tell us more Please let us know what your issue is and what help you are looking for from us If you need help with more than one issue, please choose the most urgent option above and explain the other issue here.

Consent I consent to Accommodation Concern using my information to contact me about this referral.