Homes and Money Hub Referral Form | London Borough of Barking and Dagenham

Make a Homes and Money Hub referral

Complete this form if you wish to seek help from the Homes and Money Hub. You can also refer someone for help from the Homes and Money Hub by completing this form with them.

Who are you completing this form for?

Myself

Someone else

Your name and job title

Your Service or Organisation (if relevant)

Your email address

What actions have you taken to assist the person you are referring?

Your telephone numbers

Please complete the rest of this form with the details of the person you are referring

Title

Mrs

Miss

Gender

Man

Woman

Non-binary

Transgender

Prefer not to say

First name(s)

Surname

Preferred names(s) alias/other names known by

Date of birth

Primary address

Correspondence address (if different from the primary address)

Telephone number

Email address

Marital status

Single

Divorced

Widowed

Separated

Married

Living with Partner/Civil Partner

What is your partner's full name

What is your partner's gender?

Man

Woman

Non-binary

Transgender

Prefer not to say

What is your partner's date of birth

Do any children live at your home?

Yes

Child's full name

Date of birth

Add another child?

Child's full name

Date of birth

Add another child?

Child's full name

Date of birth

Add another child?

Child's full name

Date of birth

Add another child?

Child's full name

Date of birth

Add another child?

Child's full name

Date of birth

Add another child?

Child's full name

Date of birth

Add another child?

Child's full name

Date of birth

Add another child?

Child's full name

Date of birth

Add another child?

Child's full name

Date of birth

Do any of your children have a disability?

Yes

Do you require an Interpreter

Yes

Maybe

Preferred language spoken

What is your economic status?

Are you affected by loan sharks?

Yes

Maybe

Do you have paid or unpaid caring responsibilities? (for example caring for a disabled adult or child, an elderly and/or disabled person, etc)

Yes

Do you spend money on gambling i.e., on slot machines, online gambling sites or other high street gambling shops?

Yes

Are you affected by any of these? (tick any that apply)

Substance or Alcohol misuse

Domestic Abuse or Relationship Conflict

Social Exclusion

Emergency food and/or utility need

Are you a Care Leaver?

Yes

Please indicate which of these priority debts you have

Rent arrears

Council Tax Arrears

Utility arrears

None of these

What are the issues that you need help from the Homes and Money Hub with? Please give as much detail as possible, with approximate amount of any debts and arrears

What is your housing situation?

Are you housed in this area by another Council?

Yes

Not Known

Which Council have you been housed by?

Have you or your partner (if applicable) approached any other Councils about this matter?

Yes

If so, which Council?

Have you lived outside of the UK in the last 5 years?

Yes

Not known

Are you a UK Citizen?

Yes

Do you consider yourself to have a disability?

Yes

Rather not say

Select your disability

Hearing impairment

Learning disability

Mental health problems

Restricted mobility

Speech impairment

Visual impairment

Other

What is your disability?

Does your disability mean you need home visits?

Yes

Maybe

Please confirm all types of Benefits being claimed by you and (if applicable) your partner

Are you an EU EEA National?

Yes

Maybe

Are you subject to Immigration Control?

Yes

Maybe

Do you have a current application with the Home Office?

Yes

How information will be used

The Homes and Money Hub, part of The London Borough of Barking and Dagenham (LBBD), may need to share your information with other Council departments. In addition, we may need to share your information with other services, BEAM, The Source, Letting Agencies/Landlords, the Job Shop, Citizens Advice Bureau, Debt Free Advice, the Independent Living Agency, DABD (UK), Refuge, the Department of Work and Pensions (DWP), Barking and Dagenham Reside LTD (and all associated entities/subsidiaries of) and Barking & Dagenham Homes LTD. This will enable us to help you with any concerns that you may have regarding the below. Personal information which you supply to us for the provision of these services may also be used for:

Fraud Prevention
Audit
Statistical Analysis

We will not disclose any information to any organisation outside of those listed, except to prevent fraud, or if required to do so by law.

Select which services you consent your information being shared with:

Your Money - Money management advice

Your Wellbeing - Helping to reduce financial pressures

Emergency situations - Support with food parcels or utilities during a crisis period

Your Employment - Help finding a job and keeping it

Your Home - Preventing homelessness, understanding housing choices and support with finding a home

Domestic Abuse - Referrals to internal and external Domestic Abuse services

Your Learning - Gaining new skills

Carers of Barking and Dagenham

Your declaration

I agree that personal information about me may be shared with or requested from the other agencies listed below and with other professionals e.g. BEAM, The Source, the rent service, other Council departments, the Job Shop, Citizens Advice Bureau, Debt Free Advice, the Independent Living Agency, DABD (UK) the Department of Work and Pensions (DWP), Barking and Dagenham Reside LTD (and all associated entities/subsidiaries of) and Barking & Dagenham Homes LTD so that I can be provided with services.

I understand that I have the right to restrict what information may be shared and with whom.

I understand that I may withdraw my consent to share information at any time and that this may result in a reduction of services being available.

I understand that I will be required to provide bank statements or any other documents that are requested to support my financial situation. These will be produced within 10 days.

Accepting our support will not affect any other claims for financial support or aid

I accept

Data Protection Statement

The London Borough of Barking & Dagenham processes information in accordance with the General Data Protection Regulations and is the data controller for the purpose of the Regulations.
If you would like any other information about how your information is used and your rights to access the information we hold about you please refer to our Privacy Notice www.lbbd.gov.uk/general-privacy-notice or email dpo@lbbd.gov.uk

Statistical analysis

I agree that where personal information about me is used for statistical analysis, safeguards will ensure respect for my personal information and measures such as the removal of my name will be provided.
Where my personal information is processed for statistical purposes, the conditions and safeguards above will apply although if such rights are likely to render impossible or seriously impair the achievement of the specific purpose of the statistical analysis it will be necessary to include some of your details, as necessary for the fulfilment of the statistical purposes.

Date

What is your faith? (not mandatory, for statistical purposes only)

Christian

Muslim

Sikh

Hindu

Jewish

Buddhist

No faith

Prefer not to say

Other

Tell us your faith

What is your nationality? (not mandatory, for statistical purposes only)

CAPTCHA

By clicking the submit button, you agree to the information you provide on this form being processed in line with our data protection policy.

Digital exclusion survey

Make a Homes and Money Hub referral

Please complete the rest of this form with the details of the person you are referring

How information will be used

We will not disclose any information to any organisation outside of those listed, except to prevent fraud, or if required to do so by law.

Your declaration

Data Protection Statement

Statistical analysis

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