Winter Shelter referral form

Please do not complete the referral form until you have contacted us to check whether there is space in the Winter Shelter.

Completing the form does not guarantee a place, please wait for confirmation from Inn Churches.

Inn Churches has a responsibility to ensure that agencies are competent to fulfil the requirements of the referral procedure. This includes an agreement to use appropriate guidelines.

Referral agencies have a responsibility to Inn Churches to ensure that any person delegated to deal with referrals for homeless individuals who may be eligible to access the project are competent.

Agencies acting on behalf of the project should deal with individuals face to face. Whilst the welfare of the individual is paramount, agencies also have a responsibility to consider the safety of volunteers and venues. Where the agency does not know the individual well or has doubts, this should be flagged up so that the project coordinator can make additional checks.

It is the referral agency’s responsibility to inform each homeless individual being referred that if they arrive at a venue under the influence of alcohol, drugs, solvents or legal highs, or are carrying weapons, they are at risk of forfeiting their place.

Inn Churches reserve the right to conduct bag searches in accordance with our policy. Refusal may result in a bed space being denied.

Inn Churches have a duty to ensure that records are kept of every referral and that checks carried out are in accordance with the EU GDPR (2018). Data will be stored for a maximum of six years and will not be shared with third parties beyond appropriate organisations and professionals as part of their information gathering and assessment / risk assessment processes.

Referrals must come through one of our designated referral agencies.

Referral criteria

Due to the nature of the accommodation provided and the skill levels of volunteers, it is important to safeguard the safety of host churches and teams.

Only individuals assessed as LOW TO MEDIUM risk will be admitted.

We are unable to accept individuals who:

  • are known to have committed serious violent or sexual crime, or with schedule one offences.
  • require specialist support, for example those with serious physical or mental health issues, or those who at the time of referral are heavily under the influence of alcohol, drugs, solvents or ‘legal highs’.
  • have been barred from the shelter.

If the project coordinator gives a place to an individual by phone or text, please put the completed referral form into an envelope with a copy of the shelter rules, and give this to the referred guest to present as their ‘ticket’ into the shelter on the night

Please ensure that all sections of the form are completed. In particular, referrals will not be accepted without a referral agency number.

This form should be completed by an individual working at a recognised referring organisation (the "referring agent") on behalf of the intended recipient (the "applicant").

Fields marked * are required.

A1. Applicant details

Please give details of the intended recipient.

Situation and benefits

Support worker

B. Emergency contact details or next of kin (if any)

C1. Guest responses

Please ask the guest the following questions and record their responses.

1. How long have you been sleeping rough? *

2. Where did you sleep rough? *

Question 2 omitted as not previously slept rought.

3. Why did you sleep rough? *

4. To what extent have the following factors played a part in your present situation? *

(Please select an option for each line)

Not at allLowMediumHigh

Not at allLowMediumHigh

Not at allLowMediumHigh

Not at allLowMediumHigh

Not at allLowMediumHigh

Not at allLowMediumHigh

Not at allLowMediumHigh

Not at allLowMediumHigh

5. Do you have a pet with you? *


6. Have you ever had any cautions or convictions? *

Previous offences will not necessarily stop you being offered shelter. Are you currently on DRR, DIP, probation or awaiting sentencing for any of the following?

Offence 1 details

Offence 2 details

Offence 3 details

7. Are you on any prescribed medication? *

8. Do you have any diet restrictions or concerns? *

9. Have you ever been barred from another accommodation scheme? *

C2. Guest consent to information gathering

Please get the guest to complete this section.

I confirm that the information I have given in this referral form is true and complete to the best of my knowledge.

I understand that giving false or misleading information could result in being barred from the Inn Churches winter shelter.

I understand that my stay at the Inn Churches winter shelter is conditional upon appropriate behaviour and that if I do not follow Inn Churches’ rules then I may be asked to leave.

I give permission for Inn Churches to store this information according to the EU GDPR of 2018 for a maximum of six years. I give consent for Inn Churches to share my information with appropriate organisations and professionals as part of their information gathering and assessment / risk assessment process, unless I have declared below.

D. Risk assessment

To ensure the safety of guests, staff and volunteers, please complete the following risk assessment. For each row, indicate whether this is completed using information from the client, your own knowledge or a third party.

E1. Referrer

E2. Referrer's declaration

This should be completed by you as the referring agent.

I can confirm that the applicant named above is in genuine and urgent need of accommodation and does not have an alternative bed space.

I confirm that the applicant:

  • has been assessed as low or medium risk
  • has not committed serious violent or sexual crime or schedule one offences
  • does not require specialist support, for example with serious physical or mental health issues or alcohol, drug, solvent or 'legal high' misuse.
  • has not been previously barred from the Inn Churches Winter Shelter.

I confirm that I have contacted Inn Churches to check that they have a bed space available.