Make A Referral

At Keystage we do whatever it takes to get people into safe and secure long term accommodation. However, we recognise that homelessness is not just about housing. We also offer a range of support services, bespoke to each person's own, often complex, needs.

It is very easy to refer someone to our service. Each of our properties takes in those with different needs, so please consider which is most relevant by visiting the specific location of the property on the website.

If the service is right, a referral can be made via the form below.

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Referrer Details:

Scheme Choice(Required)

Please choose the scheme you wish to refer to:

Thank you for choosing our new Northampton Service

This new scheme choice is not currently supported using this form, so please visit the dedicated form on this page to continue your referral.

If you would like to make a referral to one of our existing schemes, then please choose a different Scheme Choice above.

Choose A Service(Required)

Referrer Name(Required)

Referrer Email(Required)

Referrer Contact Phone Number(Required)

Referrer Agency Name(Required)

Referrer Agency Category(Required)

Referrer Agency Category Further Information

Individual Consent(Required)

Can you confirm that you have the consent from the individual for the information contained here in to be shared with other agencies for the purpose of assessing and addressing my housing and support needs. *

Yes

Consent For Keystage To Use Information(Required)

Can you confirm that you have the consent from the individual for Keystage Housing to obtain and provide further information, some of which may be special category information regarding any criminal or social/medical history from relevant agencies regarding their support and social needs? *

Yes

Consent To Seek Further Information(Required)

Can you confirm that you have the consent from the individual that Keystage Housing may enquire and seek further information appropriate to the application for housing and give consent for the appropriate professionals, familiar with the individuals history, housing and support needs to release information about as is deemed necessary and appropriate to the application upon request.

Yes

Service User Details

Service User Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Age Range(Required)

National Insurance Number(Required)

Service User Contact Number(Required)

Gender(Required)

Ethnicity

Ethnicity Other Information

Religion / Beliefs(Required)

Religion / Beliefs Other Information

Marriage / Civil Partnership Status(Required)

Marriage / Civil Partnership Other Information

First Language Spoken(Required)

Finances

Please give details of how the individual manages their finances:

How are finances managed?

How are finances managed other information

Does the individual have a bank account?

Yes

Not Sure

What benefits has the individual claimed in the past?(Required)

Housing Benefit

Disability Living Allowance

Personal Independence Payment (PIP)

Universal Credit

ESA - Employment Support Allowance

Income Support

Pension Credits

Working Tax Credits

Other (Please Specify)

Previous benefits claims other information

Does the individual have an active Benefits claim?

Yes

Not Sure

Please provide details of the current benefit claim

Is there an active Housing Benefit award?

Yes

Not Sure

Please provide current Housing Benefit number

Where are benefits paid to?

Personal Account

Family Account

Friend Account

N/A

Other

Does the Individual have any of the following ID?

Driving License

Passport

Birth Certificate

Citizenship Card

Home Office Letter - stating Indefinite Leave to Remain

None of the Above

Other

Can a copy of the ID be provided and verified on condition of an offer of accommodation?

Yes

Unsure

Does the Individual have any of the following debts?

None

Rent Arrears

Council Tax Arrears

Housing Benefit Arrears

Court Fines

Catalogue Debt

Personal or Payday Loans

Other

Individual Debts Other Information

Please enter any other information around debts if needed

Housing History

Please detail as accurately and comprehensively as possible. If current accommodation is prison, please provide the full address and for Date Moved In, use Custodial Start Date.

Individuals Current Address:

Street Address Address Line 2 Town / City County Postcode Country

Date Individual Moved There

Day

Month

Year

Type of Accommodation

Private Rental

Family Home

Hostel

Temporary Accommodation

Sofa Surfing

Local Authority Housing

Prison

No Fixed Abode

Other

Please give details on why you need to leave your current accommodation

Previous Address 1

Street Address Address Line 2 Town / City County Postcode Country

Date Moved In

Day

Month

Year

Date Moved Out

Day

Month

Year

Type of Accommodation

Private Rental

Family Home

Hostel

Temporary Accommodation

Sofa Surfing

Local Authority Housing

Prison

No Fixed Abode

Other

Reason for leaving

Previous Address 2

Street Address Address Line 2 Town / City County Postcode Country

Date Moved In

Day

Month

Year

Date Moved Out

Day

Month

Year

Type of Accommodation

Private Rental

Family Home

Hostel

Temporary Accommodation

Sofa Surfing

Local Authority Housing

Prison

No Fixed Abode

Other

Reason for leaving

Previous Address 3

Street Address Address Line 2 Town / City County Postcode Country

Date Moved In

Day

Month

Year

Date Moved Out

Day

Month

Year

Type of Accommodation

Private Rental

Family Home

Hostel

Temporary Accommodation

Sofa Surfing

Local Authority Housing

Prison

No Fixed Abode

Other

Reason for leaving

Has the Individual ever been evicted?

Yes

Please give details on evictions

Does the Individual have a local connection to the area?

Yes

Please describe the local connection you have to the area i.e. employment, family member...

Health and Well-Being and Support Needs

This section helps us to understand how best we can support the individual, any urgent needs such as registration to the GP, who is already providing support and what housing options may be suitable.

Does the Individual smoke cigarettes?

Yes

Not Sure

Does the Individual have any history of misusing substances with any of the following:

Alcohol

Cannabis

Class A Substances: Heroin

Class A Substances: Crack Cocaine, Cocaine

Spice

Prescribed Medication

None

Other

If other, please give details here

Is the Individual engaging in Drug or Alcohol Support?

Yes

N/A

Current Drug & Alcohol support provider:

Please give details on historical, current and future engagement of drug and alcohol support and any details of treatment or prescriptions:

Does the Individual have a historical or current diagnosis of Mental Health?

Yes

Unsure

Has the Individual engaged with any of the following services?

Community Mental Health Team

Crisis Team

Wellbeing Service

Support from GP for Mental Health

Other

Service Engagement Other Information

Please give details on any mental health diagnosis and difficulties:

Is the Individual on any prescribed medication?

Yes

Please provide details of the Individuals current prescriptions

Does the Individual have any of the following health conditions?

None

Asthma

Visual Impairment

Hearing Impairment

Mobility Difficulties

Diabetes Type 1

Diabetes Type 2

Arthritis

Hepatitis A

Hepatitis B

Hepatitis C

HIV

COPD

Deep Vein Thrombosis (DVT)

Epilepsy

Food Allergies

Allergies

Please provide any further information regarding the Individuals' Physical Health needs:

Is the Individual registered with a GP?

Yes

Unsure

Please provide details of the GP including Name and Address

Harm Screening

Please identify any relevant risk indicators below including details about the behaviour and any protective factors that mitigate the level of risk.

Has the Individual ever been convicted of the following:

Murder, Attempted Murder, Conspiracy to Murder or Manslaughter

GBH/Wounding (Section 18 or Section 20 Offences Against the Person Act)

Any sexual offence against a child(ren)

Rape or serious sexual offence against an Adult

Any other offence against a child

Aggravated Burglary

Arson

Criminal Damage with Intent to Endanger Life

Possession of Illegal Substances with Intent to Supply

Kidnapping/False Imprisonment

Possession of a Firearm with Intent to Endanger Life

Racially Motivated or Racially Aggravated Offence

Robbery

Any offence involving possession and/or use of weapons

Any other serious offence e.g. Indecent Images, Stalking, Harassment etc.

Please provide details of the most recent offence:

Date of Offence

Day

Month

Year

Factors relating to the offence: i.e associates, circumstances.

Length of Sentence:

Has the Individual ever:

Assaulted / Threatened Staff

Assaulted / Threatened others

Been violent towards a partner, family member or any other person with which they have lived with

Committed a serious offence whilst not complying with medication

Been sentenced to 4 years imprisonment or more

Been involved in any hate based behaviour

Been assessed as a High Risk of Harm

Been a conditionally discharged patient subject to a restriction order under Section 41 MHA 1983

Received an Extended Sentence

Damaged property or criminal damage

Displayed stalking behaviour (whether convicted or otherwise)

Displayed obsessive behaviour linked to offending

Bizarre or ritualistic behaviour linked to offending

Acted inappropriately towards staff or other visitors / service users

Been involved or suspected involvement in gang activity / organised crime

Please provide any further details here

Risk of Re-Offending and Risk of Harm Assessment

Is the Individual being released from a custodial sentence?

Yes

Release Date

Day

Month

Year

Probation Office Individual is reporting to

Name of Responsible Officer

Responsible Officer Email

Responsible Officer Telephone Number

Are there any local area exclusion zones?

Yes

Please give details of any area exclusion zones

Please provide any additional conditions attached to standard licence:

Exclusion Zones

No contact conditions relating to a specific individual (please provide details below)

Requirement to engage with Drug Rehabilitation

Conditions relating to the Register of Sex Offenders

Please provide details of the no contact conditions

Please provide details of the individual's history and pattern of offending e.g. summary of previous convictions, repeat victimisation / targeting, triggers or dis-inhibitors to offending etc.

OGRS 2 Year Re-conviction Score:

Risk of Harm Assessment

Who is at risk of harm?

What is the nature of the risk?

When is the risk likely to be the greatest?

What factors are likely to reduce the risk?

Is the person registered as a PPO?

Yes

Unsure

Is the individual subject to MAPPA?

Yes

What level of MAPPA is the individual monitored under?

Level 1

Level 2

Level 3

Has the next MAPPA meeting been confirmed?

Yes

TBC

N/A

Date of next MAPPA meeting:

Are there other agencies involved to support the individual?

Children's Services / Adult Social Care

Mental Health Worker / CPN / Psychiatrist

GP - Counselling

Drug / Alcohol Worker

Police - PPU

IOM

Voluntary / Charity Organisation

Other

Please provide any details of other agencies involved here

Please give details of the support / monitoring provided i.e individual is supported weekly, monthly etc...

Please provide any information regarding risk of exploitation (both to the individual and to others)

Is the Individual suitable to be supported from a Lone Working Female?

Yes

Unsure

Is the Individual suitable to be supported from a Lone Working Male?

Yes

Unsure

Is the Individual suitable to sharing accommodation with others in a HMO?

Yes

Unsure

Is there any other information you would like to provide to us?

Luton

Our Luton site - a Homeless Assessment Rapid Resettlement Pathway (HARRP) - provides 32 high quality living facilities, alongside tailored support for individuals faced with rough sleeping.

Find out more

Northampton

Our Northampton site provides 27 high quality rooms in a 24-hour staffed building for single people and a small number of couples. A female-only area is also available. All offer a safe, secure and comfortable space to stay.

Find out more

Hitchin

Our Hitchin site is the most recent addition to the safe and secure accommodation we provide across the three counties we currently operate in.

Find out more