CHAI Referral Form

Name of person making referral *

Email of person making referral (for autoresponse)

Contact telephone number

Date of referral

Name of client *

Address of client *

Name of client's Housing Officer *

Post code

Date of birth

Phone number

Client email address

Tenancy start date

Monthly rent

Other members of household

Earned income

Any means tested benefits (eg UC)?

Any disability benefits (eg PIP)?

Reason for referral

Other information

Action taken including any known risk factors

Crisis Intervention Service Green (early intervention tenancy support required)
Amber (support issues identified requiring urgent support)
Red (tenancy failure is at immediate risk/social work referral for issues)

Client consent *

The customer has received information about Community Help & Advice Initiative (CHAI) Tenancy Support and Money Advice Services. They understand that Tenancy Support or Money Advice staff may carry out a full assessment of their needs and provide the appropriate support and advice. Please tick this box to confirm that the customer has given their consent for the referral.

CHAI Referral Form

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