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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 details
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
Mr
Mrs
Ms
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
No
Children details
Child's full name
Date of birth
Add another child?
Children details
Child's full name
Date of birth
Add another child?
Children details
Child's full name
Date of birth
Add another child?
Children details
Child's full name
Date of birth
Add another child?
Children details
Child's full name
Date of birth
Add another child?
Children details
Child's full name
Date of birth
Add another child?
Children details
Child's full name
Date of birth
Add another child?
Children details
Child's full name
Date of birth
Add another child?
Children details
Child's full name
Date of birth
Add another child?
Children details
Child's full name
Date of birth
Do any of your children have a disability?
Yes
No
Do you require an Interpreter
Yes
No
Maybe
Preferred language spoken
Economic status
Cannot work (disability or long term illness)
Full-time student
Government Training/ Work Programme
Job Seeker
Not Seeking Work
Retired
Child under 5
School Age
16-18 Years Old
Adult Student
Working Full Time
Working Part Time
Other
What is your economic status?
Are you affected by loan sharks?
Yes
No
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
No
Do you spend money on gambling i.e., on slot machines, online gambling sites or other high street gambling shops?
Yes
No
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
No
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?
Private Rented Tenant
Council Tenant
Non Council Social Housing (Housing Association)
Living with family
Living with friends
Temporary Accommodation
Lodger
Looked after placement
Night Shelter
No Fixed Abode
Owner
Street Homeless
Sofa Surfing
Tied Tenant
Other
What is your housing situation?
Are you housed in this area by another Council?
Yes
No
Not Known
Which Council have you been housed by?
Have you or your partner (if applicable) approached any other Councils about this matter?
Yes
No
If so, which Council?
Have you lived outside of the UK in the last 5 years?
Yes
No
Not known
Are you a UK Citizen?
Yes
No
Do you consider yourself to have a disability?
Yes
No
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
No
Maybe
Please confirm all types of Benefits being claimed by you and (if applicable) your partner
Are you an EU EEA National?
Yes
No
Maybe
Are you subject to Immigration Control?
Yes
No
Maybe
Do you have a current application with the Home Office?
Yes
No
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 and the Department of Work and Pensions (DWP). 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) 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.
Consent
I accept
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)
How would you describe your ethnicity?(not mandatory, for statistical purposes only)
White British
White Irish
Any other White background
Traveller of Irish Heritage
Gypsy/Roma
White and Black Caribbeanb
White and Black African
White and Asian
Any other mixed background
Asian Indian
Asian Pakistani
Asian Bangladeshii
Any other Asian background
Black Caribbean
Any other Black background
Chinese
Any other ethnic background
Rather not say
Information not obtained
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
.
Leave this field blank