How to apply – Sustain UK

PLEASE READ CAREFULLY
This form is for agencies and organisations referring on behalf of their client only. For self-referrals please contact sustain head office by either emailing Referrals@sustainuk.org or by calling our office on 0121 428 2221

All sections of this form must be completed.
Failure to do so may cause delays.
If for any reason a section cannot be filled out, please state why.
Blank sections will not be accepted. Additional documents can be attached and uploaded at the end of the application form.
If for any reason you cannot fully complete this form, you can save your progress securely and resume it later. You will have 30 days to complete the form before the data is erased from our secure servers.
Sustain (UK) Ltd is an equal opportunities housing provider, however, we reserve the right to refuse referrals from persons with a history of arson (insurance regulations,) sex offences against children and fire arms offences.
Name of Referral Agency*
Agency Name
Contact Name*
Prefix First Last
Phone Number*
Email*
Hidden
Date of Referral*
DD slash MM slash YYYY
Reason for Referral*
This must be accurate.
All referrals must meet the definition of 'Vulnerable Adult' -

"A Vulnerable Adult is someone aged 18 or over; who is, or may be, in need of community services due to age, illness or a mental or physical disability. Who is, or may be unable to take care of himself/herself, or unable to protect himself/herself against significant harm or exploitation."

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Applicant Name*
Prefix First Last
Address
Please provide as much information as possible.
If the applicant is currently living in a hospital/prison/hostel etc. Then please give that address.
If the applicant is homeless then please type 'homeless' in the street address.

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Contact Number for Applicant
Date of Birth
DD slash MM slash YYYY
National Insurance Number
Gender*
- Male
- Female
- Transgender
Ethnic origin as defined by the applicant*
Next of Kin and their relationship to the applicant
Next of Kin Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Next of Kin Contact Number
Is the applicant currently receiving benefits?
- Yes
- No

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Previous 5 Year Address History
Please provide as much information as you can about the previous 5 year address history.
If there were periods where the applicant was homeless, then please write 'homeless' in the street address.
Most recent previous address?
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Approximate move in date
MM slash DD slash YYYY
Tenure
Landlord Details
Reason for leaving
Previous address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Approximate Move in date
MM slash DD slash YYYY
Tenure
Landlord Details
Reason for leaving
Previous address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Approximate Move in date
MM slash DD slash YYYY
Tenure
Landlord Details
Reason for leaving
Previous address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Approximate Move in date
MM slash DD slash YYYY
Tenure
Landlord Details
Reason for leaving

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Social Worker/CPN/Probation Officer or Other Relevant Professional(s)*
Please list all applicable details.
GP Name and Address
Please provide GP name and address (if applicable)
Has the client ever been detained/sectioned under the mental health act or community treatment order?*
- Yes
- No
Please provide details*
Mental Health History*
Physical Health History*
Present Medication or Treatment*
Details of current CPA*
If appropriate this must be provided
Any other relevant information?
Does the applicant have any past, pending or current criminal offences?*
- Yes
- No
Forensic Background*
Please include full details of current/previous offences. This information must be provided if applicable.

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Applicant Consent
I give my permission for the outcome of this referral to be explained to the referral agency*
- Yes
- No
I agree to participate in a support package including support planning and assessment*
- Yes
- No
Would you like a copy of this referral sent to you?*
- Yes
- No
Signature*
Please click and drag to draw signature
Hidden
Date
DD slash MM slash YYYY

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Please upload any additional/supporting documents here
(This is not a necessary requirement)
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 15 MB.
Supporting Documentation/Additional Information
Please list information about any documents that you have attached/uploaded to this form.
Comments
This field is for validation purposes and should be left unchanged.

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Please fill in the referral application below.