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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?

Name of Authority

Homeless Officer Number

Homeless Officer Name

Homeless Officer Email

Ethnic Origin

Is English 1st Language

Preferred Language

Applicants Housing Status

Do they have links to Trafford

Right to work and reside in UK

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

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