Make a Homelessness Reduction Act Referral Online

Public authorities should use this form to refer service users they believe to be homeless or threatened with homelessness to us.


Under the Homelessness Reduction Act 2017, public authorities will have a statutory duty to refer service users they believe to be homeless or threatened with homelessness to us (for example, it is likely they will become homeless within 56 days).

It is important that agencies make these referrals to us so that we can prevent and relieve homelessness effectively.

The statutory duty is coming into effect in October 2018, however agencies are able to make a referral now if they wish to.

Before You Start

A referral does not replace a homelessness application. The referred person(s) will still need to complete a homelessness application form if they wish to seek our help. However, following a referral, we will contact the person(s) to begin enquiries.

Before making a referral, a public authority must:

  • Have consent to the referral from the person(s) being referred.
  • Allow the individual to identify the housing authority in England which they would like to be referred.
  • Have consent that the service user's contact details can be given so the housing authority can contact them regarding the referral.

  • You will need

  • Details for the service user, including their preferred method of contact.
  • To confirm that you have consent to the referral from the person(s) being referred.

  • Fair Processing

    Cannock Chase Council will hold and use any information that you enter on to this system in accordance with Data Protection and GDPR regulations.

    Your information will be used for the purposes for which you are entering it.

    We may also share this information with other departments within the Council and partners of the Council where necessary and allowed by law.

    Your personal information will not be passed on for commercial use.

    For further information on how data protection and how we process your data please visit:-

    Privacy Policy

    Are you a public body with duty to refer? *:

    If so, please choose 'Yes' and continue with the referral by pressing 'Next'

    Refering Agency Details

    Name of your Organisation * :
    Your Organisations Name * :
    Your Post or Role * :
    Your Title * :
    Your Forename * :
    Your Surname * :
    Your Email * :
    Your Telephone * :

    Clients Details

    Client Title * :
    Clients Forename * :
    Clients Surname * :
    Clients Date of Birth :
    Client aged 16 or 17 ? * :
    Clients Gender ? * :
    Clients Nationality * :
    Clients Address (or last settled address) :
    Clients Postcode (or last settled postcode) :
    Clients National Insurance Number :
    Client Currently Homeless ? * :
    When will the Client be Homeless ? * :
    Does the Client live in the Cannock Chase District ? * :
    Why are you referring the Client * :
    Does the Client have somewhere to stay tonight ? * :
    Has the Client been referred by Social Services to apply for housing as part of their assessment process ? * :
    Has the Client given consent to refer them to us ? * :
    Clients preferred method of contact * :
    Clients contact details :
    Has the Client been referred elsewhere - please provide details ? * :
    Does the Client wish us to contact any other person - please specify details ? * :

    Client Support Needs

    Is the Clients safety at risk? * :
    Provide details about the risk :
    Is the Clients leaving one of these types of accomodations? :
    Is the Client pregnant? * :
    Has the Client dependent child(ren)? * :
    Does the Client have support needs? * :
    Does the Client have support needs due to a disability? * :
    Does the Client have health/medical needs? * :
    Is the Client vulnerable due to their age? * :
    Does the Client have a physical disability? * :
    Does the Client have a mental disability? :
    Does the Client have mental health issues? :
    Does the Client have an impairment? :
    Does the Client have substance misuse difficulties (e..g. alchohol/drugs)? :
    Does the Client have a hstory of substance misuse difficulties (e..g. alchohol/drugs)? * :
    Is the Client experiencing domestic violence or abuse? * :
    Has the Client experiencing domestic violence or abuse with in the last 12 months? * :
    Is the Client experiencing harassment? * :
    Give details of any relevant medical, health issues or special/support needs of the Client?:
    Number of Adults:
    Number of Children:


    I/we confirm that we are referring the person/household to Cannock Chase District Council as we believe they are at risk of homelessness and confirm they are given thier consent to this referral.

    I agree :