Application for Housing

Apply online:

Incomplete forms may be returned to you and could delay your application

Personal Details

Accommodation

Previous Accommodation:

Address From To Reason for leaving

Medical Details

GP Details

Income Details

Please tick which types of income you receive:

Benefit Amount Next payment date
£
£
£
£
£
£
£
£
£
£
£
£

Agency Involvement



Support Needs

Would you like help with any of the following (Please tick all that apply)?

Hobbies / Interests

References

Please provide two references that can be contacted to aid your application

Referee 1

Referee 2

History

If you are currently in custody / in care:

Please list all convictions Date Sentence

Risk Assessment

We ask all referring agencies to complete a risk assessment. If you are referring yourself we will where appropriate ask a professional who knows you to complete a risk assessment.

Attach Risk Assessment

Dangerous Behaviour

Emotional / Mental health risks

Self care / Risk from others

Risk from Associates

Substance abuse

Declarations

To be signed by the applicant:
We may need to contact other agencies for information so we can process your application. This could include other housing providers, the Police, the probation/Youth Offending service, Health Authority and/or the social services’ department. The applicant agrees to this by signing the statements here:

1 I (the applicant) hereby give my authority for any relevant agency to disclose information for the purpose of dealing with my application for housing which will include sufficient information to make an assessment of my risks. I understand that this information is to be used solely in relation to my application and will not be disclosed to any other persons without my permission.

2 The details I have given in this application are true and correct. I understand that if I have knowingly or recklessly given any false information about my application, I may lose any subsequent support I receive.

3 I (the applicant) understand that individual housing and support providers may require me to complete additional risk assessment information and/or undergo a Police National Computer (PNC) check.

To be signed on behalf of the referring agency (if applicable):
By signing this form you are declaring that all the information you have provided on it is accurate to the best of your knowledge. If inaccurate or incomplete information is provided it may result in your client losing any subsequent accommodation. This application form will be kept on the service user’s file, to which the service user will have access. Any information you wish to be kept confidential must be recorded as “confidential third party information only”.

EQUAL OPPORTUNITIES MONITORING FORM – CONFIDENTIAL

We are fully committed to the active promotion of equal opportunities and we are seeking to ensure that we are available to everyone. In order to assist us with monitoring and assessing the effectiveness of this policy we would be grateful if you would complete the details requested below. The information provided will be kept confidential.


Ethnic Origin


Religion or belief


Sexual Orientation


Do you have a disability?

If yes please indicate the nature of your disability (tick all that apply)


Gender