HPAS Referral Form Client Confirmation(Required) I confirm that the client is a Newham ResidentData Collection(Required) I consent to the provided data being collected and stored1. Referrer DetailsHPAS Case Officer(Required) Officer Email address(Required) Officer Contact Number(Required) HPAS Reference Revs & Bens Ref: Reason for Referral(Required)Choose from listBenefit CapEmployment AdviceBenefit AdviceMoney AdviceEmergency SupportBenefit Capped(Required)Choose from listYesNoReasonable steps agreed in Personal Housing Plan2. Client DetailsFull Name(Required) DOB(Required) Contact Number(Required) Email address NI Number(Required) Ethnicity(Required)Choose from listAsian or Asian British BangladeshiAsian or Asian British IndianAsian or Asian British Other BackgroundBlack or Black British AfricanBlack or Black British CaribbeanBlack or Black British Other BackgroundChinese BritishMixed Other BackgroundMixed White & AsianMixed White & Black AfricanMixed White & Black CaribbeanPrefer not to sayWhite BritishWhite IrishWhite OtherAddress(Required) Post Code(Required) Date resident in Newham Please enter the date moved into NewhamTenure at address(Required)Choose from listCouncil TenantHousing Association TenantPrivate Landlord TenantLodgerOwner OccupierResidential CareLiving with ParentsLiving with Family or FriendsHomeless - Sofa SurferHomeless - Rough SleeperHomeless - HostelNationalityChoose from listAfghanAlbanianAlgerianAmericanAngolanAnguillanAustralianAustrianAzerbaijaniBangladeshiBarbadianBenineseBolivianBosnianBrazilianBritishBruneianBulgarianBurmeseCameroonianCentral AfricanChadianChineseColombianCongoleseCroatianCypriotCzechDanishDominicanDutchEcuadorianEgyptianEmiratiEritreanEstonianEthiopianFrenchGambianGeorgianGermanGhanaianGreekGrenadianGuineanGuyaneseHungarianIndianIranianIraqiIrishItalyianIvoirianJamaicanJapaneseJordanianKenyanKosovanLatvianLiberianLibyanLithuanianMalawianMalaysianMaldivianMalteseMauritanianMauritianMexicanMoldovanMongolianMontserratianMoroccanNamibianNepaleseNigerianNorwegianPakistaniPeruvianPhilippinePolishPortugueseRomanianRussianRwandanSahrawiSaint LucianSenegaleseSerbianSeychelloisSierra LeoneanSlovakSlovenianSomaliSouth AfricanSpanishSri LankanSudaneseSwedishTaiwanTanzanianThaiTogoleseTrinidadianTunisianTurkishTuvaluanUgandanUkrainianUruguayanVenezuelanWallisianYemeniZambianZimbabweanResidency statusChoose from listBritish CitizenEU/EEA CitizenCommonwealth CitizenAsylum SeekerRefugee StatusHumanitraian ProtectionUASC LeaveDiscretionary LeaveLimited Leave to RemainIndefinite Leave to RemainDisability or long term medical conditionEmployment status(Required)Choose from listCarerIn Training or EducationJobseekerNever WorkedRetiredSelf EmployedUnemployedUnfit for WorkWorkingIf Carer In receipt of benefits(Required) [NOT Claiming any Benefits] Attendance Allowance Benefits & Pension Carers Allowance Child Benefits Child Tax Credit Council Tax Benefits Disability Living Allowance (DLA) Earnings & Benefits Earnings & Pension Employment Support Allowance (ESA) Housing Benefits Incapacity Benefits Income Support Job Seeker Allowance (JSA) No Recourse to Public Funds Pension Pension Credit Personal Independence Payment (PIP) Universal Credit (UC) Working Tax Credit 3. Household DetailsHousehold StatusChoose from listCouple - with dependant childrenCouple - No dependant childrenLone Parent - with dependant childrenSingle AdultNumber of adults in employmentChoose from list0123456+Number of adults in householdChoose from list0123456+Number of children under 18 in householdChoose from list0123456+Details of any household members who have disability or long term medical condition4. Additional InformationAdditional InformationDate of referral DD slash MM slash YYYY CommentsThis field is for validation purposes and should be left unchanged.