Email address How would you prefer to be contacted? Phone Email Letter Other, please state Next of kin name and contact details (to be contacted in case of emergency) Relationship to you Reason for application Are you or have you ever had any support from Social Services (Social Care)? Yes No Are you a care leaver? Yes No Are you on a child protection plan? Yes No EQUAL OPPORTUNITIES MONITORING Gender Male Female Transgender? Yes No Don’t Know Sexuality Religion Nationality Preferred language If preferred language not English (please comment whether able to communicate in English at all) Asian or Asian British - Bangladeshi Gypsy, Romany, Irish Traveller Asian or Asian British - Indian Mixed - White & Asian Asian or Asian British - Pakistani Mixed - White & Black African Asian Other Mixed - White & Black Caribbean Black or Black British - African Mixed - Other Black or Black British - Caribbean White British Black or Black British - Other White Irish Chinese / Other Ethnic Group White Other Housing What sort of accommodation are you in at the moment? Council/housing association rented Owner occupier/shared owner Temporary accommodation Supported housing No fixed abode Private landlord Lodger Living with family and friends (if you are living with a Sanctuary tenant please give details below) Prison/offenders institution Other type of accommodation (give details below) Details If you are currently in prison/offenders institution, when will you be released? Are you currently homeless? If yes, please give details and state how long you have been homeless for Yes No
Current address (if applicable) Postcode How long have you been at this address? Previous addresses for last 3 years Reasons for leaving Is your current accommodation inappropriate for any of the following reason? Relationship breakdown Households living apart Currently living in an adapted property that is no longer required Current property in very poor condition (please give details) Other (please give details) Details Is there a statutory duty to house you? Yes No N/A Don’t know Are you on the housing register? If yes, please state which one Yes No Don’t know Have you completed a homeless application? Yes No N/A Don’t know Are you facing eviction or any court action in relation to your housing? If yes, please give details Yes No Have you ever been asked to leave, or have you ever been evicted from any previous accommodation? If yes, please give details Yes No Do you have a local connection to the area? If yes, please give details Yes No Do you have any pets/animals that you wish to be housed with you? If yes, please give details Yes No Do you need an extra bedroom on one of the following grounds? (you will need to provide proof for this) Medical grounds Carer grounds Do you need a property which is all on one level (i.e. no stairs)? If yes, please give details Yes No Do you need a lift? If yes, please give details Yes No Maximum floor level you would accept without a lift? Please state: Do you require a property with adaptations? If yes, please give details Yes No Are you under Section 117 of the Mental Health Act? Yes No 3 Children and Child Protection Further details Are you pregnant? If yes, please state your estimated due date. Yes No N/A Do you have any children? Yes No N/A Include details of contact arrangements etc.
If yes, do you have any children who are, or have: Been supported by Social Services (Social Care) Spent time in a Social Services care placement On the ‘at risk’ register / on a child protection plan Been Involved in common assessment framework Yes No N/A 4 Your Health Further details Please give your Doctor’s contact details. Do you consider yourself to have a physical disability? Yes No Are you a wheelchair user, or do you have any mobility needs? Yes No Do you have a visual or hearing impairment? Yes No Have you been diagnosed with any long term illnesses? Yes No Have you been diagnosed with a mental health condition? Yes No Do you have a learning disability? Yes No Are you on any medication? If yes, please give details of What the medication is for Dosage Whether you manage your own medication Whether you are compliant with your medication The effect on you if medication is missed, if any Yes No 5 Income Details Please give details of any benefits you currently receive Benefit, e.g. income support, DLA, ESA Amount How often paid Details of income from employment
Additional Comments: Education, Work & Training – please tick all areas you need support in and give full details below Training Education Seeking paid employment Seeking voluntary work Other I don’t want support in this area Additional Comments: Daily Living Skills – please tick all areas you need support in and give full details in the box below Cooking, preparing food, food safety Looking after yourself/personal hygiene Keeping room/flat clean / tidy Travelling Laundry Shopping Other I don’t want support in this area Additional Comments: Accommodation, Moving on and Resettlement – please tick all areas you need support in and give full details in the box below Accessing aids and adaptations Maintaining / understanding Licence or Tenancy Agreement Preventing homelessness Preparing for moving on Finding/bidding for properties Budgeting for moving on Other I don’t want support in this area Additional Comments: Being Safe – please tick all areas you need support in and give full details in the box below Personal safety Health & safety of accommodation Safeguarding from abuse Fleeing violence / abuse Living with violence Other I don’t want support in this area Additional Comments: Basic Skills – please tick all areas you need support in and give full details in the box below Reading/writing Number skills Communication/language Other I don’t want support in this area Additional Comments: Health – please tick all areas you need support in and give full details in the box below Accessing health services Managing physical health issues Managing medication Recognising / managing mental Managing suicidal thoughts Managing self harm Managing depression Exercise / mobility Giving up smoking Pregnancy Sexual health Other I don’t want support in this