Section 9: Health, medical and wellbeing We ask for this information to ensure that your new home will meet your needs. (please underline your selection) You Joint Applicant Do you consider yourself to be disabled? Yes No Yes No Are you a wheelchair user? Yes No Yes No Do you have Autistic Spectrum Disorder? Yes No Yes No Do you have mental health difficulties? Yes No Yes No Do you have any unseen disabilities which affect your Yes No Yes No ability to live independently? Do you have other disabilities? Yes No Yes No Do you need ground floor accommodation? Yes No Yes No If you have answered yes to any of the above, please explain how your disability affects you: (please underline your selection) You Joint Applicant Do you have any problems with Yes No Yes No your health or mobility? If yes, please describe: If yes, please describe? Do you have external support, Yes No Yes No e.g. from a social worker, CPN, If yes, give the name, address If yes, give the name, address and health visitor, care worker or and phone number of your phone number of your support psychiatrist? support provider: provider: Do you have a history of, or are you Yes No Yes No currently experiencing issues with For how long have you been/ For how long have you been/were drug or alcohol abuse? were you affected? you affected? If you have overcome addiction, what help did you receive?
Section 9: Health, medical and wellbeing We ask for this information to ensure that your new home will meet your needs. (please underline your selection) You Joint Applicant Do you consider yourself to be disabled? Yes No Yes No Are you a wheelchair user? Yes No Yes No Do you have Autistic Spectrum Disorder? Yes No Yes No Do you have mental health difficulties? Yes No Yes No Do you have any unseen disabilities which affect your ability to live independently? Yes No Yes No Do you have other disabilities? Yes No Yes No Do you need ground floor accommodation? Yes No Yes No If you have answered yes to any of the above, please explain how your disability affects you: (please underline your selection) You Joint Applicant Do you have any problems with your health or mobility? Yes No If yes, please describe: Yes No If yes, please describe? Do you have external support, e.g. from a social worker, CPN, health visitor, care worker or psychiatrist? Yes No If yes, give the name, address and phone number of your support provider: Yes No If yes, give the name, address and phone number of your support provider: Do you have a history of, or are you currently experiencing issues with drug or alcohol abuse? Yes No For how long have you been/ were you affected? Yes No For how long have you been/were you affected? If you have overcome addiction, what help did you receive?
Housing-Registration-Form-May-2018-1.docx