Social or Care Needs Form

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PLEASE READ THESE NOTES BEFORE

COMPLETING THIS FORM

The key principle of assessing for Social/Care points is that when we receive a form highlighting Social or Care issues that are the reason why an applicant requires to move, there will be a requirement to get some evidence to substantiate particular issues, but more importantly whether rehousing can significantly alleviate the situation.

Only one member of a household can be awarded points. If more than one person falls within the Social/Care category, please complete a form for each one and the person who is likely to have the highest points awarded will be assessed.

Points will be awarded as follows:

Priority A: Extreme 50 points

Priority B: Serious 30 points

Priority C: Significant 10 points

Please complete the form as thoroughly as possible so that we can assess points as accurately as possible.

If you have reported any issues to the Police or have other agencies involved in supporting you please provide details so we can get additional details to support your case.

We will contact you after your application has been assessed and will tell you how many points you have been awarded and how many points in total you have. This will be approximately 2 weeks after you have returned your assessment form.

If you have any difficulty reading or writing or are visually impaired or need help in completing the form, please contact us where a member of staff will be pleased to give you advice and assistance.

All applications will be treated confidentially and fairly.

SECTION 1

INFORMATION ABOUT THE PERSON

APPLYING FOR SOCIAL/CARE POINTS

Name (required)

Gender (required)

Address (required)

Telephone Number (required)

Email Address (required)

SECTION 2

Please outline the Social or care issues that you are currently experiencing (required)

Please describe how a move would alleviate the situation. (required)

Have you contacted your current landlord/Police or other agency`s about the current situation, (please provide details), and what action has been taken by them. (required)

If you require to move to our area to receive/provide support support please provide details of what this will be and who will be providing/receiving support.

SECTION 3

OTHER INFORMATION

Is there anything else that you would like to add in support of your application?

SECTION 4

DATA PROTECTION

Declaration

I hereby give permission to Knowes Housing Association to ask my family Doctor (GP), my hospital Doctor/Consultant, and any other agencies with an interest in my health for further information.

I understand that this information will be treated in the strictest confidence and that it will only be used to assess my request for medical priority for rehousing.

Signed (Please type name as confirmation) (required)

Date dd/mm/yyyy (required)