Application Form

Online Applications Form:

Type of Referral
Self-ReferralLocal Authority ReferralSocial Services ReferralOther

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Referral Detail (if applicable):

Name of Referrer

Contact details of Referrer

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Your details:

Full Name

Any previous names (if applicable)

Date of Birth

Age

Gender
FemaleMaleTransgenderNon-binaryOther

Nationality

NI Number

Telephone Number

Email Address

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Homeless Information:

Are you currently homeless?
YesNo

If yes;
How long have you been homeless for?

Have you approached a Local Authority for assistance?
YesNo

If yes, what Local Authority have you approached for homeless assistance?

Have you registered for Social Housing?
YesNo

If yes,where have you applied to for Social Housing?

Do you have children?
YesNo

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History:

Address History (Over past 3 years)
Previous address1?

Dates of stay (to and from)?

Accommodation type?
PrivateRentCouncilParentsFriendOther
Reason for leaving?

Previous address2?

Dates of stay? (to and from)?

Accommodation type?
PrivateRentCouncilParentsFriendOther
Reason for leaving?

Previous address3?

Dates of stay? (to and from)?

Accommodation type?
PrivateRentCouncilParentsFriendOther
Reason for leaving?

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About you:

Do you drink alcohol?
YesNo

If yes, how often and how does it affect you?

Are you or have you ever been dependent on alcohol?
YesNo

Have you used illegal drugs?
YesNo

If yes, please give details of the drugs you used last and when?

Do you have a drug/alcohol worker? If yes, give details

Do you have any of the following conditions?
AsthmaEpilepsyAllergiesDiabetesOtherNone

Do you take any prescribed drugs?
YesNo

If yes, please give details of the prescribed drugs?

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Mental Health:

Do you have a history of any of the following?
Psychiatric careSuicide attemptsSelf HarmOthernone

If yes, please give details?

Do you have any formal or informal mental health diagnosis, for example PTSD, depression, anxiety?
YesNo

If yes, please provide details

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Offending History:

Have you ever been arrested? If yes, how many times and what were the alleged offences?

If yes, what was the outcome?

Do you have any previous convictions?
ViolenceDrugsTheft/BurglaryMotoring offencesCounty linesOtherNone

Do you have a Probation or Youth Offending worker?
YesNo

Are you on a community service order, ASBO etc?
YesNo

Do you need support with legal matters not related to offending?
YesNo

Do you have any court cases pending? If yes, please give details

Have you ever been a victim of a crime? For example, Child Sexual Exploitation, Violence or Cuckooing.

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Your Support Needs:

Do you need support with any of the below:

Keeping your home safe, clean and tidy
YesNo

Rent arrears
YesNo

Paying rent
YesNo

Claiming benefits
YesNo

Budgeting
YesNo

Debt advice
YesNo

Family links & Friends
YesNo

Domestic abuse
YesNo

Isolation
YesNo

Behaviour management
YesNo

Other agencies
YesNo

Training & Education
YesNo

Employment
YesNo

Volunteering
YesNo

Literacy needs
YesNo

Language needs
YesNo

LGBTQ Support
YesNo

Getting a doctor
YesNo

Getting a dentist
YesNo

Exercise or Diet
YesNo

Hygiene
YesNo

Mental health support
YesNo

Are you pregnant?
YesNo

If yes, what is the due date?

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Are there any other areas you would like support with?

Do you have anyone you can turn to for emotional support?

Do you have a Social Worker, Personal Advisor or any other Statutory Support in place?
YesNo

If yes, please provide their name and contact details.

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Your Financial Situation:

Do you have any debt including rent arrears? (if yes please provide details)

Are you in receipt of any of the following benefits?
Housing BenefitDLA/PIPUniversal CreditEmployment Support AllowanceOtherNone

Are you working?
YesNo

If yes, how many hours a week do you work and what are your weekly earnings?

Are you in education or on a training course?
YesNo

If yes, what course, where, and what hours and days do you attend?

Do you do any voluntary work?
YesNo

Do you have any savings over £3000?
YesNo

What are your future aspirations and plans?

I can confirm that the information I have given is correct. I understand that if any information I have
provided is found to be false you may withdraw any services or offer of a service, including housing,
or if I have already moved into a property managed by Hinckley Homeless Group you may take legal
action, which may result in you asking me to move out.

I give my permission for staff at Hinckley Homeless Group to disclose information held by them so
that investigations into by housing circumstances can be made.
I understand that enquiries will be made to any relevant agencies who may be able to help in these
investigations (including social care, youth offending, probation, medical, legal, benefits, Housing
Associations or landlords etc) copies of this authorisation may be used in the enquiries by Hinckley
Homeless Group.

Appeals process
If you are unhappy about any decision made in the application process, you can appeal in writing to
the Project Manager at Lawrence House. Please ask for a copy of the Appeals Process.