I have read the guidance and understand my role as referrer
Who is making this referral?
I'm referring myself
Referrer's Name & Organisation
I consent to the use of my personal data in accordance with Refugees at Home data policy
Where did you here about us?
Word of Mouth
Please state what responsibility you will continue to take on behalf of your client to sort out any outstanding issues, such as NASS accommodation, employment, status etc and agree that you will continue to be available as a point of contact should any problems arise.
The following questions refer to the Guest
Guest Contact Details
Date of Birth
Country of Origin
2nd Dose + Booster
Guest current situation
Current Living Situation
Staying with Friends/Family
Immigration Removal Centre
Home Office Asylum Support
Solicitor name and practice
Date arrived in UK
Guest Immigration Status
Human Rights Application
Survivor of Trafficking
LTR - Residency Rule
Ukrainian Sponsorship scheme
Ukrainian Family Visa
Other organisations providing support
What financial support does guest currently receive?
Guest's Personal Details
Who is this application for?
Just the named guest
The guest and their partner
The guest and their family
If other, please clarify who this application is for?
Number of Male Adults (> 18 yr)
Number of Female Adults (> 18 yr)
Number of Children (< 18)
How does the main guest identify their gender?
Prefer not to say
If other, please indicate the main guest gender
Guest languages (at conversational level or more)
If other, please indicate the guest languages
What is your highest level of education?
No Schooling Completed
Does guest have a criminal conviction?
Does the guest have any mobility condition we need to be aware of?
Yes, severe limitations
Yes, Moderate limitations
Please explain mobility condition
Guest's accomodation needs
Date placement needs to start
How long is the hosting needed for?
Emergency hosting (<1 month)
1 full month
1 - 3 Months
3 - 6 Months
Does the guest have a preferred location?
Please indicate location preference
London - Any
London - North
London - North East
London - North West
London - East
London - South East
London - South
London - South West
London - West
Tyne and Wear
If other, please indicate location preference
Why does the guest prefer that location?
Any additional details on sleeping arrangements?
Does the guest have a problem with any pets?
What type of pets would be a problem?
If other, please indicate what type of pets would be a problem?
Does guest smoke?
Is the guest vegetarian?
Does anyone in guest's group have any mental health condition?
Yes, mild issues
Yes, moderate issues
Yes, severe issues
Please provide details (symptoms, triggers, etc)
Indicate guest's group COVID vaccination status
Are there other things that we should be aware of?
Please tell us more about interests and hobbies
Please tell us a little more about the guest i.e what they do in their spare time, personality, how they interact with others and their move-on plan. This information helps us make the best matches when it comes to placements
Note: Refugees At Home will only share this information with those who need it to make and support a placement (our team, potential hosts, home visitors) and as required by law.
I confirm that I have explained the Refugees at Home data policy to the person I am referring and that they give consent for their personal data to be stored and used by Refugees at Home for the purposed of hosting
I agree that all the information provided is true and accurate
I confirm that I understand the scope of services being provided by Refugees at Home