Our work is focused on preventing people from becoming homeless by keeping people in their own homes or helping to resettle people to a new home. For those who want to move on from emergency accommodation, we also provide over 70 places in our housing services.

If you are experiencing homelessness or you are at risk of becoming homeless, you can get in touch with our team by completing our online referral form below. Alternatively, if you would like to make a referral by phone, you can contact our team on 091381828.

Make a Referral

If you are making a referral on behalf of yourself, please select ‘Self Referral Form’ below or if you are an agency worker making a referral on behalf of your client, please select ‘Agency Referral Form’.

Agency Details

Agency name:*
Name of person making referral
Name of person being referred
Client’s date of birth*
What is your client’s household type
  • - Select an option -
  • Single
  • Lone Parent
  • Couple
  • Couple with Family
Contact number:*
Agency worker’s email address *
Client’s email address
Current address:*
Do you require

Housing

Are you currently homeless?
  • - Select an option -
  • Yes
  • No
Do you have rent arrears?
  • - Select an option -
  • Yes
  • No
Is your current accommodation suitable?
  • - Select an option -
  • Yes
  • No
Do you have a notice to quit?
  • - Select an option -
  • Yes
  • No
Do you have a history of homelessness/previously accessed homeless services?
  • - Select an option -
  • Yes
  • No
Please provide details of reason you may have to leave current accommodation?
What assistance do you hope to receive from galway simon?

Support

Do you suffer from a physical health condition?
  • - Select an option -
  • Yes
  • No
Are you currently accessing treatment or support for this?
  • - Select an option -
  • Yes
  • No
Do you have any mental health issues?
  • - Select an option -
  • Yes
  • No
Are you currently accessing treatment or support for this?
  • - Select an option -
  • Yes
  • No
Are you struggling with addiction?
  • - Select an option -
  • Yes
  • No
Are you currently accessing treatment or support for this?
  • - Select an option -
  • Yes
  • No
Please specify whether you have any other needs and if you are accessing treatment for these?
What assistance do you hope to receive from galway simon?

Additional Information

Do you have a medical card?
  • - Select an option -
  • Yes
  • No
Are you registered for housing with a local authority?
  • - Select an option -
  • Yes
  • No
Please select which local authority
  • - Select an option -
  • Galway County
  • Galway City
  • Other
Are you in receipt of social welfare?
  • - Select an option -
  • Yes
  • No
I understand that the information disclosed on this form to Galway Simon Community may be shared with necessary parties in the referral process once formal consent is given and that it may be electronically stored on Galway Simon Community’s internal system in line with Data Protection requirements.

Personal Details

Name:*
Date of birth*
What is your household type
  • - Select an option -
  • Single
  • Lone Parent
  • Couple
  • Couple with Family
Contact number:*
E-mail address
Current address:*
Do you require:

Housing

Are you currently homeless?
  • - Select an option -
  • Yes
  • No
Do you have rent arrears?
  • - Select an option -
  • Yes
  • No
Is your current accommodation suitable?
  • - Select an option -
  • Yes
  • No
Do you have a notice to quit?
  • - Select an option -
  • Yes
  • No
Do you have a history of homelessness/previously accessed homeless services?
  • - Select an option -
  • Yes
  • No
Please provide details of reason you may have to leave current accommodation?
What assistance do you hope to receive from galway simon?

Support

Do you suffer from a physical health condition?
  • - Select an option -
  • Yes
  • No
Are you currently accessing treatment or support for this?
  • - Select an option -
  • Yes
  • No
Do you have any mental health issues?
  • - Select an option -
  • Yes
  • No
Are you currently accessing treatment or support for this?
  • - Select an option -
  • Yes
  • No
Are you struggling with addiction?
  • - Select an option -
  • Yes
  • No
Are you currently accessing treatment or support for this?
  • - Select an option -
  • Yes
  • No
Please specify whether you have any other needs and if you are accessing treatment for these?
What assistance do you hope to receive from galway simon?

Additional Information

Do you have a medical card:*
  • - Select an option -
  • Yes
  • No
Are you registered for housing with a local authority?
  • - Select an option -
  • Yes
  • No
Please select which local authority
  • - Select an option -
  • Galway County
  • Galway City
  • Other
Are you in receipt of social welfare?
  • - Select an option -
  • Yes
  • No
I understand that the information disclosed on this form to Galway Simon Community may be shared with necessary parties in the referral process once formal consent is given and that it may be electronically stored on Galway Simon Community’s internal system in line with Data Protection requirements.