Birmingham Mind
Housing Related Floating Support
Eligibility Application Form
Referrer Details (if Applicable)Full Name
Job Role
Address
Contact No:
Initial Support Needs
Reason for referral/Mental Health Difficulty
Personal Details
Title / Mr Mrs Miss Other / Gender / Male
Female
Forename/Surname / Marital Status
Current Address
Contact No. / Email:-
Date of Birth / Age / N.I. No.
Ethnic Origin / Nationality
Employment Status / Employed / Unemployed
Religion
Living circumstances
/ Living with parents
Living with family/friends
Living in council accommodation
Living in housing association accommodation
Living in temporary accommodation
Homeowner
Look to take up a tenancy
Currently in hospital /
/ Living in residential care home
Living in private rented property
Just left hospital/treatment centre
Just left prison/hospital/armed forces
Sleeping on the streets
No fixed address
Other, please specify HOSTEL
Preferred Language / Interpreter
Required / Yes
No
Communication Needs / Large Print
Braille / Mini Com
Audio / Signer
Translation / Other
Dependants / Yes
No x / Ages of Dependants / 0
Preferred method of Contact / Telephone
/ Via Post
/ Via Email
/ Text
/ Visit
Please state who you would preferred to be interviewed by:
Male Female No preference
*Please note advisors carry out of office assessments in pairs.
Floating Support Needs
SupportRequired / SupportRequired
Help in setting up a home / / Other (please state) /
Issues relating to safety and security / / Being healthier including physical and mental health. /
Support to access community facilities / / Further information if needed
Advice and guidance to carry out daily living skills /
Support to access other services /
Prevention of eviction from current accommodation /
Summary of Risk and Needs Defined by Applicant Defined by refferer
Violence
Arson
Sex Offence / Offending Behaviour
Suicide
Self Harm / Any other significant risk
Details of any safety issues to you or to others
Declaration
I declare that the information I have provided on this form is correct.
I understand that Birmingham Mind will arrange to meet with me and carry out a detailed assessment of my support needs.
I understand Birmingham MInd may need to contact any person or organisation that is currently providing me with a service to support my application.
The client would like to be updated in respects of the status of the application. Preference of service: not stated.
Applicant Signature: / Date
Birmingham Mind Services
Please indicate if you wish to be referred to other Mind services.
Supported Housing Services
Residential Services
Community Life Connections
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