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Housing Form
First Name
Last Name
D.O.B
Phone
Safe to call?
Yes
No
Current Address
Email
Reason for being homeless?
Has this person got a homeless application open with a local authority?
Choose an option
Name of Authority
Homeless Officer Number
Homeless Officer Name
Homeless Officer Email
Ethnic Origin
Choose an option
Is English 1st Language
Choose an option
Preferred Language
Applicants Housing Status
Do they have links to Trafford
Right to work and reside in UK
Choose an option
If homeless state reason
Previous Refuge Stay (where & when)
National Insurance Number
Employment Details
Benefits? Details benefits and amounts.
Debts. Detail any creditors and amounts owed.
Detail use of drugs
Detail use of alcohol
Detail any Mental Health issues.
Detail any Disabilities.
Detail any Medications.
Detail support services involved.
Conviction History.
Support Needs
Abuse
Mental Health
Emotional
Budgeting
Cooking
Employment
Education & Training
Social & Community Involvement
Household Skills
Communication
Other
Any Children's Details Including D.O.B
Is Applicant Pregnant?
Yes
No
Due Date:
Previous Addresses
Date From & To
Domestic Abuse
Perpetrator Name
Perpetrator Address
Perpetrator D.O.B
Perpetrator Relationship to Applicant
Any Relationship to Children
Has Perpetrator Any Issues With?
Mental Health
Alcohol
Drugs
Referrer's Details
Name
Email
Phone
Company
Submit
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