Housing Application Form APPLICATION FOR HOUSING Are you under 18?(Required)NoYesIf Yes, please contact your local Housing Department (Do NOT complete this form)Are you a Care Leaver aged 16 to 21? (or 25 years if you have a disability or in education)(Required)NoYesIf yes, contact your Leaving Care Worker before completing this formWhere do you require housing?(Required)GainsboroughLincolnAre you applying as(Required)IndividualFamily (with children or expecting)1. Personal Details (Main Applicant)Date of Application(Required) DD slash MM slash YYYY Date of Birth DD slash MM slash YYYY Name(Required) First Last Gender(Required)NI No.Current Address(Required)Post CodePhone(Required)Email(Required) Next of Kin Details(Required)Nationality(Required)First Language(Required)Other members of your household who will be accommodated with you (if applicable)Please include their names, date of birth, gender, nationality and relationship to you2. Accommodation InformationPrevious accommodation: Please provide LEAP with your past 5 years. Please be aware we will contact your previous landlord for a reference.(Required)Please include the address, landlord, when you lived there and the reason you leftWhy do you need accommodation?(Required) Sofa Surfing Family Breakdown Relationship Breakdown Rough Sleeping Eviction Harassment Overcrowding Other When will the accommodation be needed?Are you or anyone you wish to be housed with you pregnant?(Required)NoYesIf yes, when is your due date? DD slash MM slash YYYY Do you have access to children?NoYesIf yes is this for overnight?NoYesHave you approached your Local Council as homeless?(Required)NoYesDo you have a local connection to any of these Local Councils? Lincoln City East Lindsey South Holland North Kesteven West Lindsey South Kesteven Boston Other If other please state whichWhat is your connection with this council?Are you registered with this council for accommodation?YesNo3. Personal HistoryDo you, or any of the people to be housed with you, have any medical conditions, including physical disability, or mental health conditions?(Required)NoYesIf Yes please give details including medication taken:Have you, or any of your household, experienced any problems in the following areas? Mental Health Problems Sexual Abuse Violence Crime Related Issues Domestic Abuse Long Term Illnesses Self Harm/Suicidal Ideation Bullying/Harassment Alcohol Abuse Disabilities Substance Misuse Gambling Financial Abuse New Psychoactive Substances (Legal Highs) Other Please give details of all areas tickedAre you, or any of your household, under supervision of the following (Please tick)? Probation Youth Offender Order Anti-Social Behaviour Order Suspended Sentence Drug Intervention Programme Care Order (Social Services) Care Programme Approach (Mental Health Services) IOM (Integrated Offender Management) MAPPA (Multi-Agency Public Protection Agency) MARAC (Multi-Agency Risk Assessment Conference) Other If other please provide detailsIf you are on an order when does this end?Is anyone currently in custody/ In Patient(Required)NoYesIf you are in custody what is your Prison Number?If you are being released from custody, what type of supervision will you have on release?Are you awaiting a court hearing/outstanding Charges?(Required)NoYesAre you on bail?(Required)NoYesIf Yes please give details of charges and date in court:Do you, or any of your household, have any prior convictions for any of the following? Arson Drink/Drug Related Sex Offences Burglary Violence/Harassment Criminal Damage Weapons Offences against children or vulnerable adults Other Please list all convictions (is application)Please include what the conviction was for, date received and sentence4. Agency InvolvementAre there any other agencies involved with you or your household? Tick all that apply(Required) No agency involvement Probation Youth Offending Children’s Services Mental Health Services Early Help Leaving Care Team Targeted Youth Support Outreach/Floating Support Young Addaction Drug & Alcohol Services Other Please give details of any servicesPlease include the name of the service, any case workers you have with them, a contact telephone number and email address and your next booked meeting with themName of Referral AgencyName of Referring WorkerReferrer's Phone No.Referrer's Email Address5. Income DetailsPlease tick which types of income your household receives Independent Living Allowance Income Support (IS) Job Seekers allowance (JSA) Universal Credit Employment Support Allowance (ESA) Incapacity Benefit DLA/Personal Independence Payments Educational Bursary In full time employment In part time employment Attending an Apprenticeship Other Not in receipt of income/benefits Please give details of how much you receive, when you are next due to be paid and who receives these paymentsIf not in receipt of benefits have you applied?(Required)NoYesIf Yes – Which benefit and when did you apply?6. Tenancy Management NeedsWould you like help with any of the following?Sustaining a tenancyMoving on (Applying for housing/ Setting up bills)Finances (Paying rent/Claiming Benefits/Budgeting)Is there anything else you would like help with?7. Risk Assessment (only complete this section if you are from a referring agency)Areas of Risk Presented by Applicant - To ThemselvesPlease specify the areas of risk and if they are Low, Medium or HighAreas of Risk Presented by Applicant - To OthersPlease specify the areas of risk and if they are Low, Medium or HighAreas of Risk Presented by Applicant - From OthersPlease specify the areas of risk and if they are Low, Medium or HighPlease attach an agency risk assessment if applicableMax. file size: 128 MB. 8. DeclarationTo be completed by the applicant(Required) I have read and agree to the below disclaimerThe details I have given in this application are true and correct. I understand that if I have knowingly or recklessly given any false information about my application, I may lose any subsequent support I receive.9. ReferencesWe will need to make contact with 2 other agencies for references so we can process your application. This could include other housing providers, the probation service or the social services’ department. The applicant agrees to this by signing the statements here:Consent for Reference 1 I (the applicant) hereby give my authority for the agency listed below to disclose or request information for the purpose of dealing with my application for housing. I understand that this information is to be used solely in relation to my application and will not be disclosed to any other persons without my permission.Agency NameConsent for Reference 2 I (the applicant) hereby give my authority for the agency listed below to disclose or request information for the purpose of dealing with my application for housing. I understand that this information is to be used solely in relation to my application and will not be disclosed to any other persons without my permission.Agency NameTo be signed on behalf of the referring agency (if applicable) I confirm that the information provided is accurate to the best of my knowledgeBy signing this form you are declaring that all the information you have provided on it is accurate to the best of your knowledge. If inaccurate or incomplete information is provided it may result in your client losing any subsequent accommodation. This application form will be kept on the service user’s file, to which the service user will have access. Any information you wish to be kept confidential must be recorded as “confidential third party information only”.Data Protection Act 1998 and General Data Protection Regulation (GDPR)Under the Data protection Act 1998 and GDPR, we have a legal duty to protect any personal information we collect from you. - We will only use personal information you supply to us for the reason that you provided it for. - We will only hold your information for as long as necessary to fulfil that purpose and will destroy your information in line with legislation. - We will aim to store all information safely and securely and will only share with third parties when necessary and with your approval. - All employees and contractors who have access to your personal data or are associated with the handling of that data are obliged to respect your confidentiality.10. Equal Opportunities MonitoringEthnic Origin Mixed White and Black Caribbean Mixed White and Black African Mixed White and Asian Other mixed background White British White Irish Other White Background Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Other Asian background Black and Black British - Caribbean Black and Black British - African Other Black background Chinese Other background Do not wish to disclose Religion or belief Buddhist Christian (All denominations) Hindu Jewish Muslim Sikh No Religion Other Do not wish to disclose GenderIs your gender the same as you were assigned at birth? Yes No Don't Know Sexual OrientationDo you have any disability? Yes No Don't Know If YES please indicate the nature of your disability (tick all that apply) Mobility Mental Health Visual impairment Learning Disability Hearing impairment Autistic spectrum condition Progressive disability/chronic illness (e.g. MS, Cancer) Other Do not wish to disclose
