Application Form for Housing & Support

Please answer all the questions as honestly as possible to enable us to help you as much as possible with your application for housing and support.

Who is filling out this form?

A: You

B: Both you and someone else together

1: About You

Date of referral:

First Name:

Last Name:

Gender:

Male

Female

Other

Date of Birth:

Previous names you have been know by?

Current Address:

Post Code:

Contact Number:

Email:

National Insurance Number:

Nationality:

Languages Spoken:

Do you need an intepreter?

Yes

2: Supporting Organisation / Referrer

If you are an organisation supporting this application, please complete the following section:

Name of Organisation:

Name of person completing this section:

Relationship to applicant:

Address:

Contact number:

Email:

Are you completing this whole form on behalf of the applicant?

Yes

Please tell us in what capacity and for how long you have known the applicant?

Are there any other support services working with you at the moment?

Please tell us what you think the applicant's housing and support needs are:

For the applicant: Is it ok for us to contact this person/organisation?

Yes

4: Accommodation

Have you had your own tenancy before?

Yes

Please tick any or all boxes - which type of accommodation would be most suitable:

A shared house with other tenants
My own place living on my own
Ground floor
First floor or above
Do you need a:

Bath

Shower

Please list any accessibility requirements:

If you are requesting to live with a pet please tell us what type? (this is on a case by case basis and will have to be discussed during your initial assessment).

Type of pet?

Which area are you applying for?

Choice 1

Choice 2

Choice 3

Are there any areas you need to avoid?

Please list any local connections you have to the area in which you want to live (family, friends etc):

6: Affordability

This is to help work out if you can afford our accommodation:

Are you in employment, education or training?

What benefit or income to you receive, please give us as much information as possible to help us process your application?

Is there anything else you would like to tell us to support your application?

7: Accessibility

Are there any issues we need to consider if we invite you to a face-to-face assessment? (e.g. wheelchair user/visual or hearing impairment etc) Please

Please sign to say that you agree that this information is true and accurate:

Full name of applicant:

Date:

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