SOUTH DUBLIN COUNTY COUNCIL
HOUSING WELFARE SOCIAL WORK SECTION REFERRAL FORM
PLEASE TYPE OR PRINT IN BLOCK LETTERS AND COMPLETE ALL SECTIONS OF THE
FORM
(Please note that the housing welfare social work section is available to tenants of South Dublin
County Council only)
A) Basic Information
1) Client Name: 2) Address
3) Contact Phone Number 4) P.P.S Number
5) D.O.B: 6) Housing Status (Sole or Joint Tenant)
6) HWO Reference (if known): 7) Rent A/C No: (if known)
8) OCCUPANTS
Name Relationship DOB PPS number
B) Referral Summary
1) Date of Referral: 2) Referred By:
3) Referrer’s Contact Number: 4) Email Address
5) Referral Category (Please tick the relevant category)
Tenant in rent Arrears [ ]
Tenant requiring support due to breach of tenancy [ ]
Tenant requiring support related to living conditions [ ]
Tenant purchaser in loan arrears [ ]
Other as per special request from SDCC management (Please Detail Below) [ ]
6) Details regarding referral and presenting issue
8) Is there any potential risk to staff (e.g. violence, aggression)?
Please detail:
9) Please explain the nature of your involvement with this tenant(s):
10) Other agencies involved:
Contact Name Organisation Address/Phone Number Nature of involvement
11) Tenants request for support and consent to information storage:
I agree to the following statements:
- Staff from the Housing Welfare Section can contact me and/or the referrer to discuss referral.
- Housing Welfare Section staff can share and receive information about me with relevant section
within the council/ senior management and/ or other agencies that are involved (or may need to be
involved) in my case for the purpose of addressing my housing needs
- Housing Welfare Section can store information about me on their secure database as per the South
Dublin County Council data retention policy
Print name: ______________________________
Signature: ______________________________
Witness: ______________________________
Date: ______________________________
Please return via email to: dutysocialworker@sdublincoco.ie or by post to: Duty Social Worker,
Housing Welfare Section, South Dublin County Council, County Hall, Tallaght, Dublin 24.
Referrals for Housing Welfare/Social Work Service are only accepted from other agencies and
services (i.e. clients cannot refer themselves).
Incomplete referral forms cannot be accepted.
