Application for Housing Posted on 11th May 2018 Apply online: Incomplete forms may be returned to you and could delay your application Personal Details Date of Application: Surname: Forenames: DOB: Gender: MaleFemale NI Number: Current Address: Postcode: Contact Telephone Number: Email Address: Next of Kin: Are you aged 16 or 17? NoYes If Yes have you had an Initial Assessment conducted by Social Services?NoYes Accommodation Previous Accommodation: Address From To Reason for leaving Why do you need accommodation?Rough SleepingFamily BreakdownSofa SurfingIn custodyRelationship BreakdownLeaving CareOvercrowdingOther When will the accommodation be needed? Service Required?Supported HousingFloating SupportEmergency Accommodation24 Hr SupportedSelf ContainedShared Are you registered with a Local Council? NoYes Which Council are you registered with?Lincoln CityEast LindseySouth HollandNorth KestevenWest LindseySouth KestevenBostonOther Please state other: Do you have a local connection to any of the above? NoYes If yes what is your connection: Medical Details GP Details Name of GP: Address: Contact Telephone Number: Do you have any medical conditions, including physical disability, or mental health conditions? NoYes If yes, please give details: Are you currently taking any medication? NoYes If yes, please give details: Income Details Please tick which types of income you receive: Benefit Amount Next payment date Income Maintenance (LC) £ Income Support (IS) £ Job Seekers allowance (JSA) £ Employment Support Allowance (ESA) £ Incapacity Benefit £ DLA £ Educational Bursary £ In full time employment £ In part time employment £ Attending an Apprenticeship £ Other £ Not in receipt of income/benefits £ If not in receipt of benefits have you applied? NoYes If yes - which benefit? Date Applied: Agency Involvement Are there any agencies involved with you? NoYes If yes which agenciesProbationYouth OffendingChildren's ServicesMental Health ServicesTargeted Youth SupportLeaving Care TeamYoung AddactionOutreach/Floating SupportDrug & Alcohol ServicesOther Name of Service: Name of Worker: Address: Contact Telephone Number: Email Address: Details: Date of next meeting: Name of Service: Name of Worker: Address: Contact Telephone Number: Email Address: Details: Date of next meeting: Is a Professionals meeting required? NoYesDon't know Support Needs Would you like help with any of the following (Please tick all that apply)? Primary NeedsMental HealthPhysical HealthAlcohol UseMedicationDrug UseSelf HarmReducing offending/reoffendingDomestic AbuseAnti Social behaviourMoving on (Applying for housing/ Setting up bills) Secondary NeedsReading and WritingPersonal hygieneMathsFinances (Paying rent/Claiming Benefits/Budgeting)Attending AppointmentsLiving Skills (Cooking/Laundry/Shopping)Communication NeedsFinding Work/Education/Training) Is there anything else you would like help with? Hobbies / Interests Please detail any hobbies or interests you may have: References Please provide two references that can be contacted to aid your application Referee 1 Name: Title: Contact Details: Referee 2 Name: Title: Contact Details: History Have you experienced any problems in the following areas (Please tick)?Mental Health ProblemsSexual AbuseViolenceCrime Related IssuesDomestic AbuseLong Term IllnessesAlcohol AbuseDisabilitiesSubstance MisuseGamblingFinancial AbuseOther Please give details: Are you under supervision of the following (Please tick)?ProbationYouth Offender OrderAnti-Social Behaviour OrderSuspended SentenceDrug Intervention ProgrammeMAPPACare Programme Approach (Mental Health Services)IOM (Integrated Offender Management)Care Order (Social Services)MARAC Date your order expires: Other: If you are currently in custody / in care: What is your Prison Number? What is your expected release date / end of service? If you are being released from custody, what type of supervision will you have on release? Are you awaiting a court hearing/outstanding Charges? NoYes Are you on bail? NoYes Please give details: Do you have any convictions for any of the following (Please tick)?ArsonDrink/Drug RelatedSex OffencesBurglaryViolence/HarassmentCriminal DamageWeaponsOtherOffences against children or vulnerable adults Do you have any allegations for any of the above? NoYes 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. Does your agency carry out Statutory Risk Assessments? YesNo If Yes, is the most recent Risk Assessment attached? YesNo Attach Risk Assessment Dangerous Behaviour Known incidents of Violence? YesNo If yes, to whom? StaffPublicSexual assault / exposureFamilyFriends / AssociatesAnger management / Impulsive behaviour Severity of incidents No issueMinor injuryKnown danger to childrenSerious injuryDeathAbuse / harrassment of others Occurrence OnceOccasionallyDeliberate damage to property / Arson Emotional / Mental health risks Detained under the Mental health act YesNo Known history of suicide attempts YesNo Persistent provocative behaviour YesNo Personality disorder YesNo Dual diagnosis YesNo History of self harm YesNo Self care / Risk from others History of serious self neglect YesNo History of being abused / exploited YesNo Accidental harm (e.g. Kitchen fires, careless smoking YesNo History of being harassed YesNo History of domestic abuse YesNo Physical health issues YesNo Risk from Associates Known risk from Family YesNo Known risk from Friends YesNo Are they in contact? YesNo Substance abuse Drug abuse YesNo Alcohol abuse YesNo Legal highs YesNo 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. Signed: Print Name: Date: 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”. If form is sent electronically tick box Signed: Print Name: Agency: Date: 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 Asian or Asian BritishIndianPakistaniBangladeshiOther Asian background Black and Black BritishCaribbeanAfricanOther Black background Chinese or other ethnic groupChineseOther backgroundRefused MixedWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther mixed background WhiteBritishIrishOther white backgroundIrish travellerTravellerGypsy/RomanyOther If you selected other please state your Nationality: Religion or belief BuddhistChristian (All denominations)HinduJewishMuslimSikhNo ReligionOtherDo not wish to disclose Sexual Orientation BisexualGayHeterosexual('straight')LesbianDo not want to discloseOther Do you have a disability? YesNoDon't know If yes please indicate the nature of your disability (tick all that apply) MobilityMental HealthLearning DisabilityVisual impairmentAutistic spectrum conditionHearing impairmentProgressive disability/chronic illness (e.g. MS, Cancer)OtherDo not wish to disclose Gender MaleFemale Is your gender the same as you were assigned at birthYesNo
