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 Submit 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.