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Find a home
Find a home
Housing Register
Homelessness
Mutual exchange
Saxon Court
Other housing options
Your home
Your home
Your tenancy
Rent and payments
Day-to-day Repairs
Damp, Mould and Condensation
Safety in your home
Major Improvement Works
High rises
Building Safety Agreements
Leaseholders
Customer Engagement
Buy a home
Estates and environment
Home Contents Insurance
Leaflets
Advice and support
Advice and support
Cost of Living
Domestic Abuse Support
Money advice
Antisocial behaviour (ASB)
Safeguarding
Solihull Independent Living Service (SILS)
Squatters and subletting
Your right to an advocate
About us
About us
Work with us
Service Standards
Policies and procedures
Our responsibilities
Responsible Persons
News
Latest News
Newsletter
Board
Strategic Vision & Delivery Plan
Executive Leadership Team
Performance
Information Governance
How we spend our money
Social Housing Regulation
Equality and Diversity
Contact us
How can we help?
Complaints
Compliments
Social media
Contact centre
Our offices
Halls for hire
My SCH Account
My Account
Search…
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Home Hazard Referral
Home Hazard Referral
Please enable JavaScript in your browser to complete this form.
This referral form is for Home Hazard Assessments only. There is currently a 10-12 week wait for these assessments to take place.
REFERRER DETAILS
Are you making a referral on someone's behalf or for yourself?
*
For myself
On behalf of someone
Referrer name
*
First
Last
Referrer Phone
*
Referrer Email
*
Relationship to customer
*
CUSTOMER DETAILS
Customer Name
*
First
Last
Customer Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Customer Phone
*
Customers contact number, not a relatives etc
Customer Email
Customer Date of Birth
*
Customer Gender
*
Female
Male
Prefer not to say / Other
Customers Ethnicity
*
White- English, Welsh, Scottish or British
White- Gypsy or Irish Traveller
White – Irish or Northern Irish
White- Roma
Black British, Caribbean or African
Mixed or multiple ethnic groups- White and Asian
Mixed or multiple ethnic groups- White and Black African
Mixed or multiple ethnic groups- White and Black Caribbean
Asian or Asian British- Bangladeshi
Asian or Asian British- Chinese
Asian or Asian British- Indian
Asian or Asian British- Pakistani
Other Ethnic Group
Marital Status
*
Single
Separated
Married
Divorced
Widowed
Civil Partnership
Customer Religion
*
No religion
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Other religion
Prefer not to say / Don't know
Does the customer have any vulnerabilities?
*
Physical disabilities
Mental health conditions (e.g. depression, anxiety)
Learning disabilities
Cognitive impairments
Sensory impairments (e.g. sight or hearing loss)
Long-term illnesses (e.g. multiple sclerosis)
None
DETAILS OF SERVICE REQUIRED
Reason for referral
*
What equipment is required? (you can select more than one.). This is subject to the assessment and if it is deemed a need or requirement
*
Mop stick rails, banister rails and grab rails
Toilet seat raisers
Toilet frames and Scandia’s
Bath boards and bath seats
Shower chairs and stools
Bath steps
Bed leavers/sticks
Bed raisers
Bed table
Leg Lifters
Chair raisers
Perching Stools
Dycem non slip mat
Reacher (grabber/helping hand)
Tea trolley
Commode
Urine Bottle
Intercom handsets (if door entry system fitted by SCH)
Half step
Keyclamp rail
Lever taps
Have you had a fall at home within the last 12 months?
*
Yes
No
How would you rate your fear of falling? (1= not fearful, 10= very fearful)
Selected Value:
1
Would the customer like to hear about our chargeable assistive technology service which provides equipment to support people to remain at home longer?
*
Yes
No
DETAILS FOR BOOKING THE APPOINTMENT
Do we need to contact anyone else to book the appointment?
*
Yes -contact a representative
No -contact the customer
Representative's name
*
First
Last
Representatives phone
*
Representatives relation
*
GDPR
Would you like a copy of this email sent to you for your own records?
*
Yes
No
GDPR Statement - The information you provide will be used to assist us in understanding your enquiry. We may also use it to communicate with you and provide the services you need or are entitled to receive and to monitor our performance in providing services to you; to gather statistical information to allow us to plan future provision of services and to obtain your opinion about our services. We may share data with other council services & partner organisations to ensure records are kept accurate and to identify services or benefits you may be entitled to or interested in. It is therefore very important that you notify us if any of the information you have provided changes at any time. We may also need to share your information for the prevention and detection of fraud and/or other crimes or as the law requires. If you would like to learn more about how Solihull Community Housing uses personal data please refer to our Privacy Notice on the website.
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