Professional Referral Form Referral forms Referrer Information Full Name Organization/Agency Job Title Email Address Phone Number Relationship to Applicant Case Manager Family Member Self-Referral Other Applicant Details (The Person Being Referred) Nextsmartstep supports adults aged 18 and over. Applicant Name Date of Birth (Must be 18+) Current Housing Status Homeless In Custody Supported Housing Temporary Accommodation Other Gender Male Female Non-binary Prefer not to say Contact Number Support Needs & Eligibility Primary Support Area Homelessness Support Ex-Offender Reintegration Substance Misuse Recovery Mental Health / Wellbeing Required Services Behaviour Support Tenancy Support (Life Skills, Financial Inclusion) Resettlement Support Brief Background / Reason for Referral Risk & Safety Since the site mentions "Risk Assessments" and "Safe Environments." Are there any known risks to self or others? Yes No If yes, please provide brief details Consent & Submission Consent "I confirm that the applicant has given their consent for this referral and for their data to be shared with Nextsmartstep." Privacy Policy "I have read and agree to the Privacy Policy." Submit Referral
