Referral status: hold/waiting list/offer/withdrawn
Date received
Decision made known to referrer
Ref
Date of interview /
(for office use only)
Supported Housing Application
Please use block capitals
Your name
Date of birth
Current address
Correspondence
address
Contact tel no
Name of person
making referral
Organisation
address
Tel no
Job title

(Housing Need)

YORK HOUSING ASSOCIATION
(Housing Need)

Please tell us about your previous addresses over the last 5 years
Address / Dates / Reason for leaving
Do you have rent arrears?
If so how much?
With which landlord?
What steps have you taken to repay the arrears?
Have you ever been evicted from a previous tenancy? If so, please give details
Please tell us about your current home
Are you / Is your current accommodation
Tenant / House
Lodger / Flat
Living with relatives / Shared house/flat
Living with friends / Supported accommodation
Other
(please specify) / Other
(please specify)
How much notice do you have to give?

(Housing Need)

Do you have the use of the following?
Living room / Kitchen
Bathroom / Bedroom
Do you share any of these rooms? / Yes/No
If yes please give details
Are you in danger of losing your
Current home? / Yes/No
If yes please give details
Do you have any specific accommodation requirements?
E.g. Aidsor adaptions, no stairs, wheelchair access
Do you have a pet? / Yes/No
If yes please give details
Please indicate the type of accommodation you are interested in
Shared / Self contained
Relationship to staff/board members of the association
We are forbidden by law to 'grant benefits' (including tenancies) to employees, their close relatives, or board/committee members of York Housing Association.
Are you an employee or their close relative or board/committee member of York Housing Association?
Yes/No
I certify that the information given in this application is a true statement of my present circumstances
Signed / Date
(By applicant)
(Housing Need)
Equal Opportunities
York Housing Association is committed to implementing equal opportunities. It is the policy of the Association that no one receives less favourable treatment on grounds of colour, ethnic origin, gender, sexual orientation, marital status, religious belief, age, disability; or is disadvantaged by conditions or requirements which cannot be justified.
Monitoring of Applications
In order that the Association can monitor the implementation of its policy all applicants are requested to provide the following information which will be treated in the strictest confidence, and used for statistical purposes only. Your answers to these questions will not affect the consideration of your application in any way.
A. White / British / Irish / Other
B. Mixed / White & Black Caribbean / White & Black African
White & Asian / Other
C. Asian or Asian British / Indian / Pakistani / Bangladeshi / Other
D. Black or Black British / Caribbean / African / Other
E. Chinese or other ethnic group / Chinese / Other
F. Refused / Refused
Where did you hear about this scheme?
(For office use only)
Eligible for HB?
Yes / No
If yes:
Proof of ID / Over 18
or estranged
NI number / Income/other benefits
Savings

(Support Need)

Please give details of any support you have received

Source of Support / Contact Details / Comments
GP
Family friends inc. Partner previous partner
Cab/harp/housing support
Mental health services
Social services
Learning disabilities services
Drug/alcohol services
Probation services
Women’s aid
Young persons
services
Dentist
Other (please give details)

(SUPPORT NEED)

These are the support areas we can help you with. Please answer yes or no as we ask which ones you would like our support with.

Support Areas / Yes/No / Comments
Economic wellbeing
Claiming benefits
Budgeting/Debts/ Rent arrears
Obtaining paid work
Enjoy and Achieve
Access training/education
English language classes
Literacy and numeracy
Access leisure activities
Faith and cultural needs
Informal learning activities
Parenting skills
Voluntary work/work experience
Access other services
Child care
Family and social contacts
Be Healthy
Physical health
Mental health
Substance misuse
Mobility, aids and adaptations
Stay Safe / Yes/No / Comments
Establish a tenancy
Maintain a tenancy
Offending behaviour/ASBOs
Self harm
Harming others
Harm from others
Safety and security in the home
Move on aspirations
Positive Contribution
Develop confidence
Emotional support
Advocacy and communication
Practical home care/skills in living
Other- please specify
What are your priorities?

(Support Need)

Personal Details

Please let us know about any physical health issues we need to know about?

Do you have any disabilities that you feel we need to know about?

Please tell us about any mental health issues that we need to know about?

Do you have any addictions? (drugs, alcohol, solvents, gambling etc)

If you are using any medication that you feel we need to know about, please indicate what condition this is for. Are there any side effects?

Have you had any convictions or are you the subject of an ASBO?

Is English your first language? If not do you need a translator?

(Support Need)

Please provide any other information you think will help us assess your housing or support needs.
Data Protection
In order to assess your support application and help us deliver efficient services, we need to collect relevant personal details. We comply with the data protection act 1998 when dealing with personal data. This means that your personal data will be processed in accordance with the law. Please note we may share personal data with other organisations where appropriate.
Confidentiality
The housing support service is confidential; however some information will be shared within the support team for your project. We maintain a personal file for all our tenants which you are able to access by previous arrangement. This is kept in a locked cupboard with limited access. Once your support placement has ended, we keep your records for a year then all documents are shredded.
Your placement is funded by a government organisation called Supporting People for whom we provide anonymous statistical information.
With your permission we will contact your landlord and other agencies and share agreed information. The only time we will not maintain confidentiality is if we become aware of criminal activity, abuse of vulnerable people or believe that you are a danger to yourself or others.
Please note that we are now obliged to inform your landlord of anything that may materially affect your right to housing benefit (for example, savings, employment, pensions, inheritance etc) and your landlord has a duty to disclose this information to the housing benefit office.
By signing this form, you are consenting to York Housing Association processing all personal data provided.

Please sign to confirm that the above information is a true statement of your present circumstances and this form has been explained to you and you confirm you have understood it.

I do/do not give permission for my national insurance number to be passed to Communities and Local Government so that Supporting People can tell if their services are enabling me to live independently.

I do/do not give my permission for you to contact the agencies I have named in this form and my housing officer during the time I am receiving from York Housing Association.

I agree to sign a mandate that will be sent by York Housing Association to the relevant agency before we speak to them.

Name______
(please print)
Signature______/ Date______
Name of interviewers:
______
______/ Date______

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August 2008