Postcode Current address How long have (if applicable) you been at this address? Reasons for leaving Previous addresses for last 3 years Relationship breakdown Details Is your current Households living apart accommodation Currently living in an adapted property inappropriate for that is no longer required any of the Current property in very poor condition following (please give details) reason? Other (please give 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 Yes No Don’t know one Yes No N/A Have you completed a homeless application? Don’t know Are you facing eviction or any court action in relation to Yes No your housing? If yes, please give details Have you ever been asked to leave, or have you ever been evicted from any previous accommodation? If yes, please Yes No give details Do you have a local connection to the area? If yes, please Yes No give details Do you have any pets/animals that you wish to be housed Yes No with you? If yes, please give details Do you need an extra bedroom on one of the following Medical grounds Carer grounds grounds? (you will need to provide proof for this) Do you need a property which is all on one level (i.e. no Yes No stairs)? If yes, please give details 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 Yes No give details 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 Yes No N/A due date. Include details of contact arrangements etc. Do you have any children? Yes No N/A
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.
Supported-Living-Mental-Health-Referral-Form-2.docx