Housing Application Medical Assessment Form

Transcription

1 Reference No: Housing Application Medical Assessment Form Please read the leaflet Allocations Policy Medical Assessment before filling in this form. You should apply for a medical assessment if you think that you or a member of your household s health or disability is being made worse by your current housing situation. A disability is a physical or mental illness/impairment which has a substantial and long-term adverse effect on normal day-to-day activities. This is not an assessment of the severity of the medical condition or disability. It is an assessment of the need for another home that would ease the medical condition or disability. You do not need any letters of support from your doctor to apply. However, if you already have any information relating to your medical circumstances, you can attach this to your medical assessment form. Please return this form to: Housing and Property The Moray Council PO BOX 6760 Elgin IV30 9BX If returning by post please make sure a large letter stamp is used Buckie Access Point Elgin Access Point 13 Cluny Square Council Office Buckie 10 High Street AB56 1AJ Elgin IV30 1BY Forres Access Point Auchernack High Street Forres IV36 1DX Keith Access Point The Resource Centre 26 Mid Street Keith AB55 5AH Phone: housing@moray.gov.uk Updated: February 2014 V1

2 Guidance notes If you need any help with this form please phone us on What you should do: Fill in the medical assessment form in black ink giving as much detail as possible so we can make our decision. Sign and date the form. Return the form in person to your local access point or send it back to us. Please try to answer all of the questions. We will use the information you give us to assess your household s housing needs. This includes if you are eligible to have your heating upgraded. What happens next? We will consider the information and decide whether any medical points can be awarded. We will write to you when a decision has been made. All of the information you give us will be treated as strictly confidential. Medical assessment form 1. Name of applicant/s Date of birth Name of person/s claiming medical priority Date of birth 2. Your contact details Address you are currently living at: Postcode: Mobile number: Phone number: address: 3. Correspondence address, if different from above Address for mail only: Postcode 2

3 4. Details of your current home: Please tick the box that best describes your current circumstances: Tenure 4 Tenure 4 A Moray Council tenant A housing association tenant A tenant with another local authority A private tenant Living in a property I own A lodger In a caravan In hospital A member of the armed forces A tied or service tenancy Staying with parents Staying with relatives or friends In prison No fixed abode Other (please give details) 5.a) Is your home a: (please tick) 4 4 House Bungalow Maisonette Bedsit Number of steps outside the property Ground floor flat First floor flat Second floor flat or above Number of stairs inside the property b) Is your home: On the level Yes No On/up a hill Yes No 6. How many bedrooms are there in your current home? Of these how many bedrooms does your household have use of in your current home? (household = you and those people moving with you) 7. You should only answer this question if you live in a house or maisonette. Are there any bedrooms on the ground floor? Yes No If yes, how many? Are the ground floor bedrooms available for Yes No your household s use? 3

4 8. How long have you lived at this address? years months 9.a) Please describe the heating in your home (please tick) 4 Electric Oil Gas Solid fuel b) Is there a radiator in every room? Yes No c) Does your current heating system affect Yes No your/their health? If yes, please give details: 10. Are you a Moray Council tenant applying for Yes No a heating replacement? If yes, why do you need a heating replacement? Please tell us about your current home 11. Does your current home have any of the following facilities? (Please tick all that apply) 4 4 A bath A bath with an over bath shower A level access shower/wet room Hand rails Garage/parking space A ceiling track/mobile hoist A ramp A stair lift Other (please state) 12. Do you use any specialist equipment? Yes No If yes, please give details 4

5 13. Is there a toilet: upstairs? Yes No downstairs? Yes No 14. Is there a bathroom: upstairs? Yes No downstairs? Yes No What is this assessment about? 15. Please tell us about your/their ill health or disability and any medication that is being taken or treatment required. (Applies only to those wanting to be re-housed.) Name Medical condition Date of birth Medication / treatment Name Medical condition Date of birth Medication / treatment Name Medical condition Date of birth Medication / treatment 16. Please tell us how your/their current home affects your/their health as well as the reason for moving. (Continue on page 10 if more space is needed) 5

6 Please answer the following questions about (you and members of) your household 17. Are you/they registered blind? Yes No Are you/they disabled? Yes No Do you/they have an assistance dog? Yes No Do you/they have difficulty walking? Yes No Are you/they able to walk? Yes No 18. Do you/they have difficulty climbing stairs? 4 No Slowly (If yes please answer Question 19) With great effort (If yes please answer Question 19) Cannot climb internal stairs Cannot climb outside steps 19.a) How many internal stairs are you/they able to climb? b) How many outside steps are you/they able to climb? 20. Do you/they use any of the following? 4 Walking stick Crutches Mobility scooter Zimmer Wheelchair None 21. Do you/they have difficulty getting on or Yes No off the toilet? 22. Do you/they have difficulty getting in or out Yes No of the bath? 23. If you have an over-bath shower, do you/they Yes No have difficulty getting in or out? 24. If you have a shower cubicle or level access Yes No shower, do you/they have difficulty getting in or out? 25 a. Do you/they get Home Care at the moment? Yes No 6

7 b. If yes, how often do you/they get Home Care? (please tick) 4 Less than once a week At least once a week Most days 26. Approximately, how far in miles are you from your nearest: Shops/Post Office Bus stop 27. Do you/they need to be near support services? Hospital Yes No Doctor/Surgery Yes No Other Yes No Other support services please give details 28. Are your relatives currently giving care or support to Yes No you or a member of your household? If yes, please give details: Relative s name Relationship Relative s address Postcode How often is support provided? Phone number 29. Do your relatives have difficulty supporting Yes No you because of where you/they live? If yes, please give details: Relative s name Relationship Relative s address Postcode How often is support needed? Phone number 7

8 30. Can we contact this person to discuss Yes No your application? 31 a. Are you a car owner? Yes No b. Do you or a member of your household have Yes No access to a vehicle? 32. Do you, or a member of your household, need a property with any of the following due to your/their medical circumstances? Overbath shower Level access shower Accommodation on the ground floor with no outside or internal stairs Accommodation with a stair lift Level access entry Accommodation fully adapted for wheelchair use Sheltered accommodation 33. Do you/they use specialised equipment to Yes No manage your/their illness? Yes Is there space to store such equipment? Yes No No 34. Do you need a separate bedroom because of Yes No disabilities? (if yes, please fill in questions below) Name of person needing extra bedroom Are they currently having to share a bedroom? Yes No If yes, who with?... Reason that an extra bedroom is needed (medical grounds only) Do you/they have a full-time carer? Yes No 36. Are you/they in receipt of Higher Disability Living Yes No Allowance? (care component) or Personal Independence Payment (PIP) If yes, please submit a copy of the confirmation with this form 8

9 37. Are you/they in receipt of Higher Yes No Attendance Allowance? If yes, please submit a copy of the confirmation with this form 38 a. Have you/they attended hospital for emergency Yes No treatment for your/their medical condition(s) in the last 6 months? If yes, when did you/they attend?... /... /... Please give details below. Make sure you tell us the name of the hospital and why you/they attended. b. Have you/they stayed overnight in hospital Yes No (for non- emergency treatment) due to your/ their medical condition(s) in the last 6 months? If yes, when did you/they attend?... /... /... Please give details below. Make sure you tell us the name of the hospital and why you/they attended. You must fill in questions (A) and if applicable (B). This information is important to help us to process your medical needs. 39(A) Name of doctor: Address of doctor: Postcode: Phone number: (B) Name of specialist: Address of specialist: Postcode: Phone number: 9

10 Please use this space to tell us any additional information Please make sure that you sign the declaration on page 11/12. If you do not sign the declaration the form will not be assessed and will be returned to you. 10

11 Declaration and authority to seek information I/we confirm that the details I/we have given are to the best of my knowledge true. I/we confirm my/our agreement for you to access medical details from my/ our doctor or specialist in connection with my/our application. I/we will notify you of any change in the details given on the application form. I/we agree that you can make any necessary enquiries in line with the Data Protection Act This may include sharing information with other council departments and partners. I/we authorise you to make any referrals necessary in connection with my/our application. (This might include referrals to other services such as Occupational Therapy). I/we agree to any visits that may be needed to further assess my/our situation. Signed (applicant): Date.. Signed (other adult members of the household aged 16 or over) that are included in question 15: Date.. If you have filled in this form for the applicant please fill in the section below. Signed on behalf of applicant Date.. Relationship to applicant Please tell us why the applicant is unable to fill in the form:

12 If you need information from the Moray Council in a different format, such as Braille, audio tape or large print, please contact: Je eli chcieliby Pa stwo otrzyma informacje od samorz du rejonu Moray w swoim j zyku ojczystym, Pa stwa przyjaciel lub znajomy, który mówi dobrze po angielsku, mo e do nas Se necessita de informação, do Concelho de Moray, traduzida para a sua língua, peça o favor a um amigo ou parente que fale Inglês para contactar através do: Jeigu Jums reikalinga informacija i Moray regiono Savivaldyb s [Moray Council], kuri nor tum te gauti savo gimt ja kalba, papra ykite angli kai kalban i draug arba giminai i susisiekti su mumis,,,,, Si necesitas recibir información del Ayuntamiento de Moray en tu idioma. Por favor pide a un amigo o familiar que hable inglés que: hable inglés que: Housing and Property The Moray Council PO Box 6760 Elgin IV30 9BX housing@moray.gov.uk (Wednesday or Thursday Only): D-00248