Redbridge e-forms Welfare Benefit Referral Form 1Referrer source2Referrer details3Person being referred4UK residency5Main source of Income & Other Benefits6Benefits and Payments7Health conditions8Assistance needed & File upload9Summary Please use this form to make a referral to the Welfare Benefits service. Please provide as much information as possible as the team are unable to assist you/residents without a valid referral. Please call 020 8708 4180 or email if you have any queries Referrer Source* Self-referral Friend/Relative/Carer/appointee LBR internal External Organisation Friend/Relative/Carer/AppointeeBefore completing this form, you must have the resident’s permission to do so.* Please confirm you have permission to refer the resident and share their personal data About youFirst name*Last name*How would you like us to contact you?* Telephone Email Telephone*Email* TelephoneEmail Your relationship to resident (person you are referring)*LBR Staff (internal) referralBefore completing this form, you must have the resident’s permission to do so.* Please confirm you have permission to refer the resident and share their personal data LBR internalHousingChildren’s’ ServicesAdult ServicesCouncil TaxBenefits ServiceResources directorateWork RedbridgeHASS hubEducationReachout teamLeaving Care TeamHousehold Support FundOtherReferrer Name*Referrer Job Title*Referrer department*Referrer Location*Referrer Telephone*Referrer Email External organisation referralBefore completing this form, you must have the resident’s permission to do so.* Please confirm you have permission to refer the resident and share their personal data About the referrer External OrganisationCitizens AdviceJCPGeneral PractitionerMellmead HouseLandlordNELFTOne Place EastRedbridge CarersRedbridge CVSRegistered Social LandlordSalvation ArmySHPWelcome CentreOtherReferrer Name*Referrer Job Title*Organisation name*Department*Referrer Telephone*Referrer Email Self ReferralAbout youFirst name*Last nameDate of birth* Day Month Year National Insurance Number*How would you like us to contact you?* Telephone Email Telephone*Email* TelephoneEmail Address (Enter Postcode)*Find addressSelected address About the person you are referring to our serviceFirst name*Last nameDate of birth* Day Month Year National Insurance NumberHow would they like us to contact them?* Telephone Email Telephone*Email* TelephoneEmail Address (Enter Postcode)*Find addressSelected address About your UK residencyAbout their UK residencyAre you a British Citizen?YesNoAre they a British Citizen?YesNoDo you have the Right to reside in the UKEU Pre Settled StatusEU Settled StatusLimited leave to RemainIndefinite Leave to RemainNoneI don’t knowDo they have the Right to reside in the UKEU Pre Settled StatusEU Settled StatusLimited leave to RemainIndefinite Leave to RemainNoneI don’t knowAbout the property you live inAbout the property they live inDo you*Own your own home or have a mortgageRent your home from a private landlordRent your home from Redbridge CouncilRent your home from a Housing AssociationLive in Temporary accommodation provided by Redbridge Housing ServicesLive in a hostel that provides you with supportOtherDo they*Own their own home or have a mortgageRent their home from a private landlordRent their home from Redbridge CouncilRent their home from a Housing AssociationLive in Temporary accommodation provided by Redbridge Housing ServicesLive in a hostel that provides them with supportOtherIf Other, please specifyIf Other, please specifyAbout other people that live with you. About other people that live with them. Do you live on your own*YesNoDo they live on their own*YesNoDo you have a partner*YesNoDo they have a partner*YesNoPlease provide your partner’s detailsPlease provide their partner’s detailsFirst name*Last name*Date of birth* Day Month Year National Insurance NumberHow many children under 18 years live with you?012345More than 5How many children under 18 years live with them?012345More than 5How many other adults live with you?012345More than 5How many other adults live with them?012345More than 5More about youMore about themDo you have any communication difficulties (Please tick all that apply)* Sight Impairment Hearing Impairment Cognitive challenges Language challenges None Do they have any communication difficulties (Please tick all that apply)* Sight Impairment Hearing Impairment Cognitive challenges Language challenges None If English is not your first language and you will require an interpreter, please state your first language*If English is not their first language and they will require an interpreter, please state their first language* About your main source of income. Do you receive any of the following?About their main source of income. Do they receive any of the following?Please tick all that apply Bereavement Support Payment Child Benefit Child Tax Credit Earnings from an employer Earnings from self-employment Earnings from being the Director of a company Employment and Support Allowance (ESA) Fostering Allowance Guardian Allowance Income Support (IS) I have no income Jobseeker’s Allowance (JSA) Other income Pension Credit Private/Occupational Pension State Retirement Pension Statutory Sick Pay Universal Credit Widowed Parent’s Allowance Working Tax Credit If other income, please stateDo you receive any of the following Disability related Benefits?Do they receive any of the following Disability related Benefits?Please tick all that apply* Attendance Allowance Carer’s Allowance Disability Living Allowance Personal Independence Payment None I don’t know Carer’s Allowance -please state who you care for Do you receive any of the following other Benefits and Payments? Do they receive any of the following other Benefits and Payments?Please tick all that apply* Housing Benefit Council Tax Reduction Discretionary Housing Payments (additional help with your rent) Discretionary Hardship Payments (additional help with your Council Tax) Subsistence Payments None Other If Subsistence Payments, please state which organisation pays thisIf other, please state which organisation pays this About your health. Do you have any of the health conditions listed below.About their health. Do they have any of the health conditions listed below.Please tick all that apply. Mental ill health Learning disability / learning difficulties Cognitive challenges Brain injury Physical disability Sensory disability Neurological condition Terminal illness Other significant long term health condition or disability Care for an ill or disabled child Care for a child with significant developmental delay I do not have any of these health conditions Mental ill health*Please use this box to tell us a little bit moreLearning disability / learning difficulties*Please use this box to tell us a little bit moreCognitive challenges*Please use this box to tell us a little bit moreBrain injury*Please use this box to tell us a little bit morePhysical disability*Please use this box to tell us a little bit moreSensory disability*Please use this box to tell us a little bit moreNeurological condition*Please use this box to tell us a little bit moreTerminal illness*Please use this box to tell us a little bit moreOther significant long term health condition or disability*Please use this box to tell us a little bit moreCare for an ill or disabled child*Please use this box to tell us a little bit moreCare for a child with significant developmental delay*Please use this box to tell us a little bit more Please state exactly what assistance you would like the Welfare Benefits Team to provide*Please state exactly what assistance they would like the Welfare Benefits Team to provide*Please use this space to tell us anything else you think we need to knowFile upload (jpg, gif, png, pdf) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB. You may upload any supporting documents/ evidence you have that may help the Welfare Benefits Team to support you, such as, • letters from clinicians (GP, consultant etc) that confirm your diagnosis/medical condition(s) • social worker reports • care plans • notification letters from Department for Work and Pensions (DWP) or Pension Service (PS) about your Benefits {all_fields}Declaration* I agree to the above declaration and that the information provided is to the best of my knowledge.