Duty to refer form

Your details
Name

First name

Last name
Referring agency
Contact email address
Date of referral
Person details
Title
MrMrsMsMiss
Name

First name

Last name
Date of birth
Current or last known address

Address Line 1

Address Line 2

City

County

Postcode

Country
Household composition
SingleSingle and pregnantCoupleCouple and pregnantFamily with dependent child or childrenFamily with non-dependentsOther
Email
Phone
Preferred contact method
EmailTelephoneLetter
Referral details
Initial reason for referral
Notice given by landlordRent arrearsProperty unsuitable (health)OvercrowdingStreet homelessHospital dischargeMove on from supportedFamily / friends asking to leaveDomestic abuseLeaving carePrison releaseHarassment / ASB / violenceArmed forces leaver
Estimated date of homelessness
Additional information including any known risks
Consent
I consent to the Council capturing and storing the personal details in this form for providing the service requested. I have consent to the referral from the person(s) being referred. I understand that I (or the person being referred) can request personal details to be removed from Council records.
Confirmation of consent
I consent

Privacy

In this form, we ask for some personal information (such as name, address, date of birth, etc.) in order to fulfil your request for information or services.

This information will be held securely and will be used to provide you with the service you have requested.

Any processing will be performed in line with the requirements of the Data Protection Act 2018 and the General Data Protection Regulation.

Trafford Council is the Data Controller for the information you give us. Further details about how we process personal data can be found in our privacy notice.

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Trafford Council, Trafford Town Hall, Talbot Road, Stretford, M32 0TH