Housing Application Form YOUR DETAILS Name * First Name Last Name Like to be known as Date of birth MM DD YYYY National Insurance Number Gender Marital status Email * Phone (###) ### #### A little bit about you * We'd love to know a little bit about who you are. For example, key things such as things you like and dislike. 1. KEY CONTACT DETAILS 1.1 Who should Ling Trust speak to about your application? Name First Name Last Name Email Phone (###) ### #### Relation to you 1.2 Social Worker/ Care Manager/ Community Nurse: Name First Name Last Name Email Phone (###) ### #### Job title 1.3 Next of Kin Name First Name Last Name Email Phone (###) ### #### Relationship 1.4 GP details Name First Name Last Name Email Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country 2. COMMUNICATION 2.1 Are there ways which we could make communication easier for you? 2.2 I would prefer letters to be sent to me in: Plain English Easy Read 3. CHILDREN 3.1 Do you have any children? If no, please jump to YOUR CURRENT HOME No Yes 3.2 Name of first child If you have more than 1 child, please provide this information separately First Name Last Name 3.3 Birthdate of first child MM DD YYYY 3.4 Do you want them to live with you? Yes No 4. YOUR CURRENT HOME 4.1 Current address Address 1 Address 2 City State/Province Zip/Postal Code Country 4.2 Current living arrangements Own my own home Live with my family Rent Homeless In registered accomodation In hospital Other 4.3 Previous addresses for the past five years 4.4 Are you eligible for Section 117 Aftercare? Yes No 4.5 Are you on the housing register? You need to be on the housing register for Ling Trust to be able to help you. Yes No 4.6 Please describe the things you have tried to get suitable housing so far: 5. YOUR NEW HOME 5.1 Why I need to move: 5.2 When I need to move by Including notice on current home required, if needed MM DD YYYY 5.3 Where do you want to move to? 5.4 Do you want to live on your own, or with others? I would like to live on my own I would like to live with my partner I would like to live with other people who are not my partner 5.5 My new home needs to be this property type: Tick all that apply Detached Semi-detached Terraced Bungalow Flats/Apartments 5.6 How many bedrooms? 5.7 How many parking spaces? 5.8 A garden is: Needed Preferred Not preferred Not bothered 6. MY SUPPORT 6.1 My current support provider Name First Name Last Name Email Phone (###) ### #### Job title 6.2 My job provider when I move (if different): Name First Name Last Name Email Phone (###) ### #### Job title 6.3 How many support hours will you have when you move? 6.4 Does it include sleep in/wake in? Yes No 6.5 Funding of support package ICB / Continuing Healthcare Local Authority Joint funded 6.6 Local Authority details of who funds your care (if applicable): Name First Name Last Name Email Phone (###) ### #### 6.7 ICB Details of who funds your care (if applicable): Name First Name Last Name Email Phone (###) ### #### 6.8 My needs Tick all that apply Mobility needs Wheelchair Hoist / tracking Frame Lift / stairlift Specialised bath Wetroom Autistic Learning disability Epilepsy Mental health Registered blind 7. MAKING DECISIONS 7.1 Please tell us about how big decisions are best made for you: Tick all that apply I have capacity and am able to make decisions for myself about: Property and financial matters Personal welfare, eg. making decisions about medical treatment and how someone else is looked after. I have a Deputy/Power of Attorney appointed by the Court of Protection to make decisions on my life about: Property and financial matters Personal welfare, eg. making decisions about medical treatment and how someone is looked after I have been assessed as not having capacity and I do not have a Court of Protection Deputy 7.2 If you have a Deputy / Power of Attorney appointed by the Court of Protection, please give their details: Name First Name Last Name Email Phone (###) ### #### 7.3 If you have someone who helps you manage your day-to-day finances, please give their details: Name First Name Last Name Email Phone (###) ### #### 8. INCOME SUPPORT 8.1 Please tell us what benefits you receive: Income Support Housing Benefit Pension Credit Carer's Allowance Disability Living Allowance - Care - Low Disability Living Allowance - Care - Medium Disability Living Allowance - Care - High Disability Living Allowance - Mobility - Low Disability Living Allowance - Mobility - Medium Disability Living Allowance - Mobility - High Child tax credit Working Tax Credit Bereavement Support Attendance Allowance Personal Independence Payments - Care - Standard Personal Independence Payments - Care - Enhanced Personal Independence Payments - Mobility - Standard Personal Independence Payments - Mobility - Enhanced Universal Credit Discretionary Housing Payment Employment and Support Allowance - Support Group Employment and Support Allowance - Contribution Based Employment and Support Allowance - Income Based Employment and Support Allowance - Working Group Employment and Support Allowance - Cold weather payment Other 8.2 Please give details of the date each of these benefits were awarded, and how much you receive 8.3 Have you applied for any benefits and are awaiting to hear the outcome? If so, please give details here 8.4 Are you classed as a student? Yes No 8.5 Do you have a spouse? Yes No 8.11 Please tell us what benefits your spouse receive: Only if you ticked 'Yes' to Question 8.5. Income Support Housing Benefit Pension Credit Carer's Allowance Disability Living Allowance - Care - Low Disability Living Allowance - Care - Medium Disability Living Allowance - Care - High Disability Living Allowance - Mobility - Low Disability Living Allowance - Mobility - Medium Disability Living Allowance - Mobility - High Child tax credit Working Tax Credit Bereavement Support Attendance Allowance Personal Independence Payments - Care - Standard Personal Independence Payments - Care - Enhanced Personal Independence Payments - Mobility - Standard Personal Independence Payments - Mobility - Enhanced Universal Credit Discretionary Housing Payment Employment and Support Allowance - Support Group Employment and Support Allowance - Contribution Based Employment and Support Allowance - Income Based Employment and Support Allowance - Working Group Employment and Support Allowance - Cold weather payment Other 8.12 Has your spouse applied for any benefits and are awaiting to hear the outcome? If so, please give details here Only if you ticked 'Yes' to Question 8.5. 9. YOUR FINANCES 9.1 Do you: Have more than £6,000 in total? Have more than £16,000 in total? Own any assets (eg. investments or property)? 9.2 Are you able to afford utility bills, food and general costs of living? Yes No 10. YOUR HISTORY 10.1 Please tick where applicable Any history of: Cruelty to animals Anti-social behaviour Arson Victim of abuse Risk of targeted abuse from community Sexual offences convictions Rent arrears Evictions Hoarding Property damage Smoker Do you have / want pets Do you have a pacemaker (may not be suitable with induction hobs) For any that have been ticked, please provide further details and how this will be managed in your new home 10.2 Do you: Have fire safety awareness Know how to recognise and report repairs or breakages Know how to keep appointments with contractors Know how to ask for ID from contractors Understand when to call for emergency services Recognise if water temperatures are so hot it could cause scalding Know how to lock doors and windows and have awareness of home security Know about stranger danger Have awareness of heights and danger of falling Know how to keep the property clean Carry out gardening duties Know how to care for pets properly 11. SUPPORTED HOUSING ENVIRONMENTAL RISK ASSESSMENT 11.1 Please select the appropriate option: Likelihood of: Destruction of Property Rare Unlikely Possible Likely Almost Certain Picking of Property Rare Unlikely Possible Likely Almost Certain Banging Rare Unlikely Possible Likely Almost Certain Flooding of Property Rare Unlikely Possible Likely Almost Certain Throwing objects Rare Unlikely Possible Likely Almost Certain Tearing or chewing of objects Rare Unlikely Possible Likely Almost Certain 11.2 Hygeine Likelihood of: Smearing of bodily fluids Rare Unlikely Possible Likely Almost Certain Incontinence Rare Unlikely Possible Likely Almost Certain Self-induced vomiting Rare Unlikely Possible Likely Almost Certain Spitting Rare Unlikely Possible Likely Almost Certain 11.3 Seeking behaviour Likelihood of: Seeking or obsessing about food and drink Rare Unlikely Possible Likely Almost Certain Excessive water drinking Rare Unlikely Possible Likely Almost Certain Stealing of others' property Rare Unlikely Possible Likely Almost Certain Climbing Rare Unlikely Possible Likely Almost Certain Jumping Rare Unlikely Possible Likely Almost Certain Entering others' rooms Rare Unlikely Possible Likely Almost Certain 11.4 Sensory sensitivity behaviour Is there a sensitivity to: Light Rare Unlikely Possible Likely Almost Certain Smells Rare Unlikely Possible Likely Almost Certain Movement Rare Unlikely Possible Likely Almost Certain Traffic noise Rare Unlikely Possible Likely Almost Certain Noise of household appliances Rare Unlikely Possible Likely Almost Certain Noise of other tenants Rare Unlikely Possible Likely Almost Certain Unexpected touch of others Rare Unlikely Possible Likely Almost Certain 11.5 Communal issues Has there been: Reclusive behaviour such as isolating self in room Rare Unlikely Possible Likely Almost Certain Noise issue Rare Unlikely Possible Likely Almost Certain Behaviour likely to impact other tenants Rare Unlikely Possible Likely Almost Certain Disturbed sleep pattern likely to impact others Rare Unlikely Possible Likely Almost Certain Use of furniture as a barricade Rare Unlikely Possible Likely Almost Certain 11.6 Functional issues Are there any issues concerning: Trips and falls Rare Unlikely Possible Likely Almost Certain Needs for support with personal care Rare Unlikely Possible Likely Almost Certain Support with meal preparation and cooking Rare Unlikely Possible Likely Almost Certain Support with engaging with activities within home Rare Unlikely Possible Likely Almost Certain Need for support with recognising water temperature (scalding risk) Rare Unlikely Possible Likely Almost Certain Use of household objects to self harm or as a weapon Rare Unlikely Possible Likely Almost Certain Restrictions around food Rare Unlikely Possible Likely Almost Certain Adapted or reinforced furniture needed Rare Unlikely Possible Likely Almost Certain DATA PROTECTION ACT 2018 The Data Protection Act controls how your personal information is used by Ling Trust. We are responsible for using data and have to follow strict rules called 'data protection principles'. We must make sure information about you is: • Used fairly and lawfully. • Used for limited, specifically stated purposes. • Used in a way that is adequate, relevant, and not excessive. • Kept for no longer than is absolutely necessary. • Handled according to people's data protection rights. • Kept safe and secure. • Not transferred outside the UK without adequate protection. Permission to obtain and share information * By checking "I CONSENT", you consent to Ling Trust holding personal information about me, and they can obtain and share information about me from others, in accordance with the Data Protection Act 2018, for the purpose of assisting with my housing and related issues. Also, that the information provided is true and correct. I consent Thanks for filling out our housing application form.We’ll be in touch as soon as we’ve reviewed your information. If you have any questions or need to update your application, you can reach us at info@lingtrust.org or 07864 064824.
