Gateway Visiting Support Families Project Application

PLEASE RETURN FORM AND REFERENCE TO:

Please note a reference form must be completed by a suitable referee or your application cannot be considered.

(A suitable referee is someone who works with you in a professional capacity and has preferably known you for 6 months or longer. If you are having trouble finding a referee please contact Gateway Visiting Support and we will try to assist you.)

Name
1. Support Needs

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a)Do you already receive support from a recognised support agency?
Yes No
If yes, which one?
b)Have you received support from a recognised support agency in the past?
Yes No
If yes, which one?
c)Are you willing to receive to support?
Yes No

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d)Please indicate if you think you need help with any of the following:
General well-being
Social and recreational support
Support with health issues
Support with substance misuse
Financial support
Housing/tenancy support
Support with life skills
Support with employment and training / Please indicate any presenting issues:
Mental health issues
Substance misuse issues
Personality disorder
Offending behaviour
Learning disability
Physical health issues
Challenging behaviour
Vulnerability because of age
2. Personal Details
a)Name:
Telephone:
Nationality: / Age:
Date of Birth: / /
National Insurance Number:
Address:
Postcode: / Type of Accommodation:
(e.g. council tenancy, hostel, private let etc)
Date Moved In:
Next of Kin: / Address:
Relationship:
Telephone:
3. Children
a) Do you have children Yes No
b) Do your children stay with you? YesNo
If yes, please give their details below:
Name: / Age:
Male/Female / Date of Birth: / /
Name: / Age:
Male/Female / Date of Birth: / /
Name: / Age:
Male/Female / Date of Birth: / /
c) Please give details of any social worker involved in your children’s care.
Do you agree to us contacting the social worker for this information?
Yes No
d) Are your children receiving any other support for medical or emotional problems?
Yes No
e) Are you pregnant? Yes No
If yes, when is the baby due?
f) Will you have permanent care of the baby when it is born? Yes No
4. Employment and Benefits
a) Are you working?
No Full time Part time Voluntary Study
b) Are you claiming benefits? Yes No
c) Which type?
d)How much are you paid per week/fortnight/month from benefits/employment?
5. Housing Background
a)Please provide a brief history of your homelessness or tenancy difficulties:
b) Have you ever had your own tenancy? Yes No
c) How long did you live in this tenancy?
d) Do you have rent arrears?Yes No
e)Are you currently paying them off? Yes No
f) Have you ever been evicted from accommodation for any of the following:
Antisocial Behaviour Rent ArrearsDamage to Property
If yes, please provide details:
6. Health Issues
Name & Address of GP: / Telephone Number:
a) Do you have any physical health problems? Yes No
Please give details and state if these impact upon your ability to look after yourself or your property:
b) Do you have a diagnosed mental health problem? Yes No
If yes, please describe:
c) Do you have problems with your mental health that have not been diagnosed?
If yes, please describe: Yes No
d) Have you ever self harmed or made a suicide attempt?Yes No
e) Do you feel that you still need help with this? Yes No
f) Do you take medication for physical/mental health problems? Yes No
If yes, please give details:
7. Addiction Issues
a) Do you use alcohol? Yes No
If yes, how often and how much do you spend per week on alcohol?
b) Do you use drugs? Yes No
If yes, how often and how much do you spend per week on drugs?
c) Has your drinking, drug use or gambling ever got you into trouble? (e.g. with landlord, neighbours, police) Yes No
If yes, please provide details:
d) Do you have support for drinking, drug use or gambling at the moment?
If yes, who provides the support? Yes No
e)Would you like to access support with drinking, drug use or gambling?
Yes No
8. Social Contacts
a) Do you have family or friends who live near you? Yes No
b) Do you have contact with them? Yes No
c) Is this positive? YesNo
d) Do you often feel lonely or isolated? Yes No
If you are not from the UK:
e) Do you have difficulties with language because you are not from the UK?
YesNo
9. Offending History
a) Do you have any criminal convictions? YesNo
b) Have you spent time in prison? Yes No
If yes, please give details:
c) What was the nature of your offences?
d) Do you have any outstanding charges? Yes No
If yes, please give details:
10. Referral
Name and Address of referral agent/agency: / Name and Address of additional referee (e.g. doctor, social worker, counsellor etc):
I (name)______consent to the above people being approached for a reference in connection with my application to Bethany Christian Trust.
(signed) (date)
11. Declaration
I declare that the information I have given on this form is, to the best of my knowledge, accurate and true.
(signed) (date)

Equal Opportunities Monitoring Form

Please tick the relevant box in each of the sections below

Section 1: Gender – are you

Male / Female / Unspecified

Section 2: Age – are you

Under 16 / 16 – 19 / 20 – 24 / 25 – 39 / 40 – 49 / Over 50 / Over 65

Section 3: Ethnic Group (background or culture) – are you:

White
Scottish / English / Irish / Welsh / Other / Please specify
Asian, Asian Scottish, Asian English, Asian Welsh or other Asian British
Indian / Pakistani / Bangladeshi / Chinese / Other / Please specify
Black, Black Scottish, Black English, Black Welsh or other Black British
Caribbean / African / Other / Please specify
Mixed / Please specify / Other Ethnic / Please specify

Section 4: Disability – do you consider yourself to have

Note: The disability categories used are broadly based on the definition of a disabled person in the Disability Discrimination Act 1995 as “someone with a physical or mental impairment which has a substantial or long term effect upon his/her ability to carry out normal day to day activities”.

No disability or impairment / A sensory impairment / A learning disability
A physical impairment / A mental health condition / Any other disability or impairment

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