To request help for yourself or somebody else to keep a home please fill in a Referral Form.

Two forms are provided a “Self-Referral Form” and an “Agency Referral Form”.
If you are making a referral for yourself, please choose the ‘Self-Referral Form’. The Self-Referral Form asks for details about the person who needs help and their current housing situation. This form can be completed by the person seeking help or a personal acquaintance with the individual’s consent.

If you are making a referral on behalf of somebody with whom you have no personal relationship, choose the ‘Agency Referral Form’. The Agency-Referral Form requests information about the person at risk or experiencing homelessness and also about the individual or organisation making the referral.

Please choose the form that you think is most relevant.

Our Referral Monitor will contact you within three working days to discuss your needs and request any further information that may be needed.

Make a Referral:

Field is required!

Agency Details

Agency Referral Form
Agency making referral:*
Field is required!
Agency worker completing referral
Field is required!
Agency worker’s email address *
Field is required!
Agency worker’s contact number *
Field is required!
Is Referral Subject currently being accommodated by referring agency?
Field is required!

Client's Details

Name of person being referred
Field is required!
Client’s date of birth*
Field is required!
Client's contact number:*
Field is required!
Client's Current Address
Field is required!
Do you require
Field is required!

Housing

What is your client’s household type
  • - Select an option -
  • Single
  • Lone Parent
  • Couple
  • Couple with Family
Field is required!
Please tell us the name of Client’s local authority (county council)
  • - Select an option -
  • Donegal
  • Leitrim
  • Sligo
Field is required!
How long has client lived in this local authority area
  • - Select an option -
  • Less that 2 years
  • More than 2 years
Field is required!
Is Client approved for Housing Assistance Payment (HAP)?
  • - Select an option -
  • Yes
  • No
Field is required!
Was HAP approval issued by current local authority?
  • - Select an option -
  • Yes
  • No
Field is required!
What is Client’s current housing status?
  • - Select an option -
  • Street homeless
  • Staying in emergency accommodation
  • Staying with Friends
  • At risk of losing current accommodation
Field is required!
Does client have rent arrears?
  • - Select an option -
  • Yes
  • No
Field is required!
Does client have a notice to quit?
  • - Select an option -
  • Yes
  • No
Field is required!
If 'yes', please select the date below
Field is required!
Does client have a history of homelessness/previously accessed homeless services?
Field is required!

Support

Does client have a physical health condition requiring treatment?
  • - Select an option -
  • Yes
  • No
Field is required!
Is the client currently accessing treatment or support for this?
Field is required!
Does client have any diagnosed mental health issues?
  • - Select an option -
  • Yes
  • No
Field is required!
Is client accessing any treatment or support for their mental health?
Field is required!
Does client you have any diagnosed addiction issues?
  • - Select an option -
  • Yes
  • No
Field is required!
Is client accessing any treatment or support for their addiction?
Field is required!

Additional Information

Does Client have a medical card?
Field is required!
Are you in receipt of social welfare?
If 'yes', please state entitlement
Field is required!
Where did you hear about the North West Simon Community's services?*
  • - Select an option -
  • Donegal County Council
  • Leitrim City Council
  • Sligo City Council
  • Health Services
  • Tusla (Child & Family Agency)
  • Youth Services
  • Other Homeless Services
  • Social Welfare Services
  • Social Media
  • Word of Mouth (Family/Friends)
  • Other
Field is required!
I confirm that the person named on this form has consented to the making of a referral to North West Simon Community and that the person’s consent has been obtained in accordance with the requirements of current Data Protection Legislation.
Field is required!

Personal Details

Self Referral Form
Name:*
Field is required!
Your Date of Birth
Field is required!
Contact number:*
Field is required!
E-mail address
Please enter an email address in the format: name@exmaple.com
Current address:*
Field is required!
Postal address to which we may write to you.
Field is required!
Field is required!
Do you require:
Field is required!

Housing

What is your household type
  • - Select an option -
  • Single
  • Lone Parent
  • Couple
  • Couple with Family
Field is required!
Your local authority (county council)
  • - select a option -
  • Donegal
  • Leitrim
  • Sligo
Field is required!
Are you approved for Housing Assistance Payment (HAP)?
  • - select a option -
  • Yes
  • No
Field is required!
Was HAP approval issued by current local authority?
Field is required!
What is your current housing status?
  • - Select an option -
  • Street Homeless
  • Staying in emergency accommodation
  • Staying with friends
  • At risk of losing my current accommodation
Field is required!
Do you have rent arrears?
  • - Select an option -
  • Yes
  • No
Field is required!
Do you have a notice to quit?
  • - Select an option -
  • Yes
  • No
Field is required!
Do you have a history of homelessness/previously accessed homeless services?
  • - Select an option -
  • Yes
  • No
Field is required!
Additional Information
Field is required!

Support

Do you have a physical health condition requiring treatment?
  • - Select an option -
  • Yes
  • No
Field is required!
Are you currently accessing treatment or support for this?
Field is required!
Do you have any mental health issues?
  • - Select an option -
  • Yes
  • No
Field is required!
Are you currently accessing treatment or support for your mental health?
Field is required!
Do you have any addiction issues?
  • - Select an option -
  • Yes
  • No
Field is required!
Are you accessing any treatment or support for your addiction?
Field is required!

Additional Information

Are you in receipt of social welfare?
If 'yes', please state entitlement
Field is required!
Today's Date:
Field is required!
Data Protection: I understand that by submitting this referral form I am requesting a support service from North West Simon Community and by so doing I give North West Simon Community a "legitimate interest" entitlement to share my personal data with necessary third parties and to store my personal data in North West Simon Community’s internal records systems in line with Data Protection requirements.
Field is required!