Chesterfield Churches Housing Association Ltd

Chesterfield Churches Housing Association Ltd. Harehill Court, Harehill Road, Chesterfield.S40 2NZ Tel/ Fax: 01246 230172 Email: [email protected] www.harehill-housing.co.uk Office use: Date Received: On data base: Accepted / Rejected: Application Number:

Housing Application Form – Harehill Court

It is important that this form is completed giving as much information as possible. This will enable us not only to assess if we are able to offer a place on the waiting list but to place the applicant in the correct position on the list which may in some cases mean a higher position with greater priority, depending on your needs and personal circumstances.

1. Applicants Details:

Applicant Joint Applicant (if applicable) Title: First name/s: Surname: Address:

Please provide proof of Identification and address.

Telephone No: Email address: Previous addresses in last five years:

Current Tenure: If tenant give name and address of landlord

Date of birth: Relationship to joint applicant: National Insurance No: Gender: Marital status:

1 Have the applicant/s been convicted of any offence not spent under the provision of the Rehabilitation of Offenders Act 1974 or convicted or cautioned for any sex offence or Schedule One offence? Yes / No If yes give details:.…………………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Has legal action been taken against the applicant/s for Anti Social Behaviour? i.e Eviction, Injunction, ASBO Yes / No If yes give details…….…………………………………………………………………………….. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

2. Reason for Application:

Describe in detail why the applicant/s wish to apply for housing at Harehill Court...... ………………………………………………………………………………………………………….

3. Disabilities & Medical conditions:

Describe in detail any disabilities the applicant/s considers themselves to have. If none state none. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Give details of any medical conditions the applicant/s may have. If none state none.

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Give the name and address of doctor and any other health professional that the applicant/s see ie district nurse or CPN and the reason for their visit. If none state none.

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2 List any prescribed / unprescribed medication the applicant/s takes at the present time. An up to date repeat prescription should be attached if possible. If none state none.

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Are applicant/s: (delete as appropriate):

Registered Blind: Yes / No Registered Disabled: Yes / No Have a hearing impairment: Yes / No Have speech impairment: Yes / No Have communication difficulties: Yes / No

Does the applicant/s require a wheelchair? Yes / No

For out door use only – Yes / No For use all the time – Yes / No

Does the applicant/s require assistance to walk / move around indoors ? Yes / No

Does the applicant/s use a zimmer frame or trolley to assist with mobility ? Yes / No

Does the applicant/s have any medical conditions that require regular assistance?Yes / No If Yes give details:…………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Give details of any dietary needs the applicant/s may have. This should include any likes / dislikes, special dietary requirements and allergies. If none state none. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Have the applicant/s been diagnosed with a mental illness including: Dementia or Alzhiemers disease: Yes / No Depression: Yes / No Other: Yes / No If yes give details:… ……………………………………………………………………………….. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

3 Do the applicant/s have short term memory problems? Yes / No If yes give details:…………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Does the applicant/s have any addictions? i.e. drugs or alcohol Yes / No If yes give details:…………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Does the applicant/s have any behavioural problems? Yes / No If yes give details:…………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

4. Personal care / support:

Does the applicant/s receive any support from Social Services or Private Care Agency at the present time? Yes / No If yes give details:……………………………………………………………………………………......

If private care is received how is this funded? ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Does the applicant/s require assistance with?

 Washing & dressing - Yes / No  Meal or drink preparation – Yes / No  Assistance with incontinence needs – Yes / No  Laundry – Yes / No  Cleaning – Yes / No  Shopping or pension collection – Yes / No  Administration of medication – Yes / No  Any other support – Yes / No

4 What support would the applicant/s require if living at Harehilll Court? Yes / No If yes give details:……..……………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Does the applicant/s have a Social or Support Worker? Yes / No If yes give details:… …….…………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Does the applicant/s attend any community groups or meetings? Yes / No If yes give Details:………. …………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… Does the applicant/s enjoy socialising and mix well in groups? Yes / No If no give details:……………………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

5. Family Assistance:

Does the applicant/s have any family members living locally who assist with care? Yes / No Give contact details and details of what support is given: ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Would support continue if the applicant/s are offered accommodation at Harehill Court? Yes / No

If the applicant/s have no local family members please give details of someone who does assist and would be willing to be placed on record as an emergency contact / next of Kin: ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

5 Has anyone got Power of Attorney or Enduring Power of Attorney for the applicant/s? Yes / No If yes give details:………. …………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

6. Finances

Does the applicant/s receive at the present time:  Housing benefit: Yes / No  Guaranteed Pension Credit: Yes / No  Attendance Allowance: Yes / No  Disability Living Allowance: (care element): Yes / No  Disability Living Allowance: (mobility element): Yes / No

You may be asked to supply proof.

Is the applicant/s able to pay the specified rent (this includes those who are applying for benefit who may have to pay full rent until the benefit is approved)? Yes / No

Does the applicant/s have any or had in the past five years any rent arrears on property they have rented? Yes / No If yes give details:………. …………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Does the applicant/s receive any assistance with managing their financial and other affairs? Yes / No If yes give details:…. ………………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Do the applicant/s have any other financial commitments loans / Hp agreements etc? Yes / No If yes give details:………..…………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

6 7. Housing

Is the applicant/s isolated in their present accommodation? Yes / No If yes give details:…. ………………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Is the applicant/s homeless or about to become homeless? Yes / No If yes give details:………. …………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Is the applicant/s present accommodation unsuitable for their needs or contributing to their health problems? Yes / No If yes give details:.…………………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Is the applicant/s present accommodation in need of repair? Yes / No If yes give details:….………………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… Is the applicant/s registered on the Housing Waiting List of any other council or housing Association? Yes / No If yes give details:. …………………………………………………………………………………. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

If you were offered a suitable flat immediately would you accept it? Yes / No If No give details:…………….……………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

7 Please use this space for any other information relevant to the application: ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… 8 I/We authorise Chesterfield Churches Housing Association Ltd to make any inquiries that are required to deal with my application. This may involve contacting your G.P, Social Services Adult Care, Local authority, Primary Care Trust, Housing Association or any relevant body and give my/our permission for information regarding my application to be released to them.

I/We understand that if any false information is given this application may be suspended or cancelled.

I/We understand that if I am offered a flat that is suitable and it is declined, I/we may be placed on to the bottom of the waiting list.

All information on this application form is treated with the strictest of confidence, as is any information gained from other sources.

Declaration:

The information I provide is accurate. I understand that if I obtain accommodation by providing inaccurate information, the association may take legal action to recover the property.

Applicants signature:

Joint applicants signature:

If the applicant/s has not completed this form please state the name and address of person completing, relationship and why assistance was required: ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………

Signature:

When completed this form should be returned for the attention of the Manager at Harehill Court.

Chesterfield Borough Council has 50% nomination rights for Harehill Court. To speed up your application you may like to consider registering on their waiting list as well, indicating that you wish to be considered for housing at Harehill Court and when a flat is available a bid may be registered in person or on line for the vacancy. You can obtain information about this from Chesterfield Borough Council on 01246 345345.

9 Ethnicity

This information is required for monitoring purposes only.

Please tick the ethnic group that applies to you:  White British  White Irish  White any other white background  Mixed white and black Caribbean  Mixed white and black African  Mixed white and Asian  Mixed any other mixed background  Asian or Asian British – Indian  Asian or Asian British – Pakistani  Asian or Asian British – Bangladeshi  Asian or Asian British – any other Asian background  Black or Black British Caribbean  Black or Black British African  Black or Black British and other background  Chinese or other ethnic group – Chinese  Chinese or other ethnic group – not stated