Positive Lifestyles

POSITIVE LIFESTYLES

POSITIVE LIFESTYLES

STANDARD APPLICATION FORM.

7-11 LANCASTER ROAD,SALFORD, M6 8AQ.

TEL: 0161 789 0203

FAX: 0161 288 7171

Introduction.

This form is to be used for all Supported Housing Service applications.

Confidentiality.

This information will be treated with strictest confidence and used only by project staff for internal purposes. The only exception to this would be if in the opinion of the Project Co-ordinator / Manager, the interest of public protection took priority over confidentiality.

Eligibility Criteria.

· Will be aged 18 years and over

· Will be in need of supported accommodation

· May be at risk of offending, or is an ex-offender

· Will not be a registered sex offender

· Will not have a conviction history of Sexual offences

· Will have no significant current drug or alcohol abuse problem, which is not receiving treatment (Lancaster House, Waterside House, Supported Tenancies).

· Willing to engage in harm reduction work associated with alcohol abuse (Royal Court)

· Will not have a serious mental health problem

· Will not have any difficulties with self-care

· Will not appear through that individuals personal history represents a violent threat to hostel residents, or staff

· Will not normally have committed, or be convicted of arson

· Will demonstrate a commitment towards solving personal and practical problems alongside staff

· Will be able to live and wish to live communally where required

· Will begin to demonstrate a potential for independent living within 12 months (short stay supported housing provision)

Client Details:

Surname / Forenames
Date Of Birth / Sex / Male / Female
National Insurance Number

Marital Status:

Married Separated Divorced

Single Widowed

Ethnicity:

African Arab Asian

Caribbean European Chinese / South East Asian

European Mixed Race Irish (Republic & North)

UK Black UK White Unknown

Other

Current Address / Contact Place:

Telephone Number: ……………………………………

Person to be contacted in case of emergency:

a) Name:

b) Relationship:

c) Contact Address:

d) Contact Telephone Number:

Where was client brought up?

Place of last stable residence: Town/County:

Borough:

Main reason for seeing the client:

Housing Issues Money Problems Desire To Talk

Drinking Issues Substance Dependency Violence

Odd/Eccentric Behaviour Self Neglect Suicidal Ideas

Depression Hallucinations/Delusions Mental Health Issues

ID Requirements Legal Difficulties Other

Describe Presenting Issues:

Criminal History:

List any convictions & court disposals for each.

Do they have any outstanding Court Appearances (please give dates / details)

Please give as much detail as possible regarding criminal convictions (an attached list would be useful).

Please highlight any convictions likely to be significant to project staff and residents.

E.G. Schedule 1, violence, arson etc.

Area of Risk:

Do you think the applicant could be considered as presenting risk to any of the following:

Themselves: Yes No To Others: Yes No

To Staff: Yes No From Others: Yes No

Please give details:

Support:

What do you and the client think will be achieved by living in this supported housing project?

What support would you like the project staff to provide?

What contribution will you be able to make to work with your client during their stay?

Referring Agency:

Name & Address of Agency:

Type of Agency:

Telephone No: Contact Name:

Is client a refugee? Yes No

Is client a European National? Yes No

How long have you known the client? Weeks / Months / Years

Is the clients attendance record Good / Fair / Poor

Has the client had a homeless assessment? Please give details & contact numbers:

Asylum Seeker / Refugee Status:

Is the client an asylum seeker? Yes No

Has the client had a Habitual Residency Test Yes No

(HRT is a benefits assessment. For entitlement(s) an individual must have lived within the UK for 5 years or more).

What was the outcome of the HRT?:

When is the next HRT Due: Date:

Benefits:

Is client on benefits? Yes No

Type of benefits?

Income Support: Amount £ Weekly Fortnightly Monthly

DLA: Amount £ Weekly Fortnightly Monthly

Component: Care: High Medium Low

Incap / Sickness: Amount £…………Weekly Fortnightly Monthly

Other: Amount £…………Weekly Fortnightly Monthly

Payment Method: Giro Book Bank Card

Does the client have ID? Yes No

List forms of ID:

Current Financial Situation:

‘Official’ sources of income (tick all that apply). Weekly Basis

1. Total Amounts of Benefits
2. Employment / Casual Work
3. Borrowing from friends
4. Gets money from family
5. Other / £
£
£
£
£

‘Unofficial’ sources of income (tick all that apply)

1. Begging
2. Crime / Criminal Activity
3. Sex Industry
4. Other / £
£
£
£

Which Benefits Agency is client currently signed on at?

Name & Address:

Contact Tel No:

Debts: Amount: £ Who to Weekly Repayment £

Total Debt: £

Ability to Manage Finances: Excellent Good Average Poor

Understanding of Financial Position: Excellent Good Average Poor

Has the client a Bank / PO Account: Yes No

(IF NO: ACTION NEEDS TO BE TAKEN ON ADMISSION TO APPLY TO OPEN EITHER A BANK OR PO ACCOUNT SO BENEFITS CAN BE PAID DIRECT)

Other Agencies Involved:

For each agency involved with the client please record the following:

a) Name of contact person

b) Organisation / Type of Service

c) Address

d) Telephone No

e) Currently Involved Yes No