For office purposes only.

Date:
Appointment booked:
Triage officer:

YOU ARE NUMBER………………………………..

Housing Options Triage Form

Please fill out as much detail on this form as possible. This will help us to deal with your enquiry as quickly as possible.The content of this form will be kept strictly confidential and will not be shared with a 3rd party without your consent.

Name: / D.O.B:
Last settled address: / NI Number:
Phone Number(s):
Emails address:
Household Members: / D.O.B: / Relationship: / Employment/School address: / Moving
with you?
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
Are any of the household members moving with you pregnant? / YES/NO
If YES, who is pregnant? / E.D.D:
Do you:
Rent a private property? / YES / NO / Landlords contact number:
Rent a Social Property? / YES / NO / Landlords contact number:
Own your home / YES / NO / Mortgage Company:
Live with parents / YES / NO / Name and phone number:
Lodge / YES / NO / Name and phone number:
Do you want? / Please Circle:
Salford Home Search advice / information? / YES/NO
Private rented / Rental Bond Assistance? / YES/NO
Housing Options / Advice? / YES/NO
Homeless assistance? / YES/NO
Have you got somewhere to sleep tonight? / YES/NO
Address History (5 years): / Tenure type: / Date From / To: / Arrears: / Reason for leaving:
Please tick any of the following that apply to you:
Rent arrears (already been evicted) / Rent arrears (still living in the property)
Notice to quit NASS accommodation / Mortgage arrears
Relationship breakdown (non violent) / Relationship breakdown (violent)
Landlord issues / Disrepair / Debt / Financial issues
Harassment / Medical condition (property not suitable)
Prison release: / Other (please give details):
Please provide details of any medical conditions:
Diagnosis: / Prescribed medication:
Agency: / Name: / Address: / Telnumber: / Authorised to contact?
GP / YES / NO
Social Worker / YES / NO
Occ.Therapist / YES / NO
Home Care / YES / NO
Other (e.g. CPN) / YES / NO
Consultants / YES / NO
Drug/Alcohol / YES / NO
Do you have limited physical mobility? / YES / NO / If yes, please provide details:
Do you expect your condition to improve or deteriorate within the next 12 months?
Do you receive help from family and/or friends? / YES / NO
What type of support, if any, do you receive?
Are you: / Amounts received:
Working full time / part time / YES / NO
Claiming Job Seekers Allowance / YES / NO
Claiming medical or disability benefit(s) / YES / NO
A full time carer / YES / NO
A student / YES / NO
Other: (please advise)……………………………..
………………………………………………………. / YES / NO
Are you:
On Probation? / YES / NO / Probation Officer:
On Licence? / YES / NO
If yes, please confirm:
Criminal Convictions: / Sentence: / Prison:
Have you ever been in care? / YES / NO / If YES, When:
Have you ever been a member of the armed forces? / YES / NO, if yes please provide details:
Please use this space to provide any further information that is relevant to your current housing
situation:

Salford City Council is committed to treat everyone who uses its service fairly and with respect. We know that people do not always receive fair treatment. Sometimes this is because of their age, at other times it is because of their disability, ethnic heritage, gender, sexual orientation or religion/belief. Asking our customers for information on these issues will help us to know whether the services we provide are fair. There are laws which require us to do this in order to promote equality and eliminate discrimination.

You do not have to fill this section in, but it will assist us to offer better services. The information you provide will only be used to check what we do. There are occasions when it may be shared with other public organisations such as the NHS, In most cases, this information will remain anonymous, but where it is linked to personal data it will only be so we can offer improved and fairer services. We will always follow the laws that protect against its misuse such as the Data Protection Act 1998.

White / Mixed / Black
English / White & Black Caribbean / Black British
Welsh / White & Black African / Caribbean
Scottish / White & Asian / African
Irish / Other / Other
Other
Asian / British Asian / Chinese / Other Ethnic Group
Indian / Chinese / Jewish
Pakistani / Other
Bangladeshi / Arabic
Other / Yemeni
Other
Gender:
Male
Female
Transgender / YES
Do you consider yourself transgender
Sexual identity
Bisexual / Heterosexual / Straight
Lesbian / Gay Woman / Gay Man
Other
Religion / Belief
Do you regard yourself as belonging to any particular religion? / YES / NO
If yes, which one?
Buddhist / Christian / Hindu
Muslim / Sikh / Jewish
Other / Please state:
Age
0 - 15 / 16 - 19 / 20 - 24 / 25 - 34
35 - 44 / 45 - 54 / 55 - 64 / 65 - 74
75 +

Disability:

Salford City Council operates within the guidelines of the Disability Discrimination Act (1995) and the Disability Discrimination Act (2005). The 1995 Act defined disability as:

‘A physical or mental impairment which has substantial and long term adverse effects on a person’s ability to carry out normal day to day activities…..’(Long term means over 12 months in total or the rest of the person’s life.)

Do you consider yourself to be disabled? / YES / NO

The Disability Discrimination Act covers a wide range of disabilities including:

  • Hearing, sight, speech impairment (such as blindness and deafness) but not those which can be corrected by glasses or contact lenses for example.
  • Mobility difficulties (wheelchair use, arthritis).
  • Learning disabilities
  • Developmental difficulties (dyslexia and autism)
  • Mental health conditions (depression, OCD and schizophrenia)
  • Progressive conditions such as dementia, HIV, cancer and Multiple Sclerosis (MS)
  • Physical co-ordination difficulties or reduced physical capacity (chromic back pain, respiratory illnesses)

If you are unsure as to whether you should consider yourself as disabled, please call the Equality Human & Right Commission helpline on 0845 604 6610 for further advice.

FOR OFFICE USE ONLY: Additional information.

Housing Options:
Homelessness: