Application for Short Term Supported Accommodation (Under 2 Years)

Transcription

1 Application for Short Term Supported Accommodation (Under 2 Years) Short term Supported Accommodation aims to help you to develop the skills to live independently and move on to more independent accommodation In order to be eligible to apply you must: 1. Be in need of Accommodation where support is provided. 2. Be willing to work with a support worker towards becoming more independent 3. To be willing and able to pay your rent. About You Mr/Mrs/Miss/Ms.. Full Name.. Address Postcode.. Date of Birth.. Contact telephone No Male Female Alternate contact details (please give address). Letter Through another person. Please give details Do you need this form in another language or format? Yes If Yes, please give details. No 1

2 Please tell us about where you live now. Is it? At home with parents/ Partner Staying with friends Bed & breakfast Hostel Private Rented Housing Association Other - please state Where have you lived in the last 5 years? Address Why did you leave? 2

3 What type of support do you need to take up and manage this accommodation? Please tick any which apply to you. Managing your Housing Understanding your tenancy agreement. Knowing your rights and responsibilities Perhaps you have had problems in the past. Income and Benefits Claiming relevant benefits, the importance of Housing Benefit claims understanding reviews. The tax credit system or help with the returning to work/training financial benefits. Bills and Budgeting How to prioritise debts, understanding utility bills, methods of payment. How to make and balance a budget. Managing your Health needs Registering with a G.P Managing poor health, attending appointments. Accessing Mental Health Support agencies. Managing your Drug or Alcohol use. Training / Education/ Employment Returning to training, education Adult classes/ college Paid or voluntary work Household Management Basic food nutrition, setting up household routines, learning to live independently. How to report a repair. What is a landlords responsibility. Daily Living Activities What you do with your time Help to develop a daily/ weekly routine. Joining in community activities Accessing community facilities Personal Admin/Communications Help to deal with post and forms. Making claims on time. Speaking to other agencies, dealing with queries. How to get advice and information. How to make complaints. If you are helping someone to complete this form please give your name and contact details. Name Organisation.... Contact Telephone No.... 3

4 Please give details of any support you currently receive Support network Names Contact details Friends/Family General Practitioner Social Worker Connexions Worker Probation Service/ Youth Offending Team Psychiatrist/ Psychologist Community Mental Health Nurse Community Psychiatric Nurse Learning Difficulties Service Drug or Alcohol service Advocate/ Other WHERE WOULD YOU LIKE TO LIVE? PLEASE SEE LEAFLET FOR DETAILS OF SCHEMES AVAILABLE First choice Second choice 4

5 In order to consider your application it is important that we know enough to be able to support you, to keep you safe and to maintain the safety of our other tenants and support workers. More about you: Are you a care leaver when did you/ do you leave? Are you pregnant? Expected date of delivery? Are you fleeing domestic violence or violence from someone else? Do you feel at risk from harm or abuse? Do you have problems which stop you doing things or cause you pain and discomfort? Have you ever received treatment for your mental health? Do you have periods of feeling low in mood or experience depression? Where you live now affects your mental health? Do you have a recognised learning disability? Did you have help at school? Do you have difficulty with reading and writing? Yes Details 5

6 Do you misuse Alcohol? Do you use illegal drugs Have you ever been violent towards others? Have you ever caused damage to property? Have you committed Arson? Are you an ex offender? Are you on probation? Yes Are you engaged in a treatment programme Are you engaged in a treatment programme Are you engaged in a treatment programme What was the result of this What was the result of this Have you re offended Details Data Protection Any personal information that you supply is confidential and will be held by South Gloucestershire Council in accordance with the Data Protection Act. Declaration and Consent. Please read the declaration below carefully and then sign it. The information I have given on this form is complete and true. I agree to it being used by South Gloucestershire Council to assess my housing and support needs. I consent to South Gloucestershire Council or any other partner agencies seeking additional information from other agencies, or accommodation providers to assist my application for Short Term Supported Accommodation. I consent to South Gloucestershire Council sharing the information that I have given, or that has been given about me, with relevant partner agencies on a need to know basis. Signed:. Date:... 6

7 Ethnic Origin: This section is used for monitoring purposes only. Please tick the box which best reflects your ethnic group. White British Irish Other: Please state. Mixed Black/white Caribbean White/Black African White/Asian Other: Please state. Asian or Asian British Indian Pakistani Bangladeshi Other: Please state Black or Caribbean Caribbean African Other: Please state.. Chinese or other ethnic Group Chinese Other ethnic group.. I do not wish to complete this section When completed please return this form to: South Gloucestershire Council Housing and Support Access Service PO Box 2083 Council Offices Castle Street Thornbury South Gloucestershire BS35 9BR Telephone Fax Floating support@southglos.gov.uk 7