SSL - Application Form

FIRST STOP REFERRAL FOR SUPPORTED ACCOMMODATION IN NORTH LINCOLNSHIRE

Please find below a description of each of the supported accommodation projects. STAGE 3 PLACE OF CHANGE, SCOTTER HOUSE, DORCHESTER ROAD, DN17 1QH - Place of Change is short term supported accommodation and is for individuals who are/or facing homelessness including rough sleepers with complex needs such as Mental Health, Drug & Alcohol Addiction, Offending behaviour and learning disabilities. The service offers support 24/7 and it is an expectation that service users will engage and be prepared to make positive changes. They offer 1-1 support in housing related support, managing a home, budgeting, benefits, managing health and move on daily/weekly group work in Tenancy Program, Healthy Eating, Basic Maths & English, Art and Wrap, Recovery Café. Opportunities to volunteer within the project and their café. Management and support is provided by Creative Support. - SELF REFERRALS NOT ACCEPTED.

CONWAY HOUSE, COTTAGE BECK ROAD, DN16 1LG - Conway house is short term supported living for people with medium/high support needs, requiring intensive weekly support. Clients are rough sleeping or homeless, with additional support needs including mental health, substance misuse, learning disabilities or offending behaviour. Support with budgeting, managing rent payments, daily living skills, saving money/support for move on, setting up housing applications/bidding on properties, preventing homelessness, claiming benefits, children contact arrangements, and keeping them safe. They also facilitate a move on course at Conway House which covers the above areas in more detail. Management and support is provided by Sanctuary Supported Living.

PARKERS LANE (OFF ASHBY HIGH STREET) , DN16 2JY – Parkers Lane is a longer term supported accommodation for those individuals with long and enduring mental health. They offer individual support and also have three drops ins per week. The service supports individuals with all housing related support - managing their home, budgeting, benefits, daily living skill and with move on from the service. Parkers Lane works very closely with Mental Health Services in supporting individuals in managing/improving their mental health and recovery. Management and support is provided by Creative Support.

STAGE 2 CROSBY MEWS, FERRY ROAD WEST, DN15 8RH– Crosby Mews accommodation is provided and managed b y Home Group. Service Eligibility is 18 years plus , single homeless or risk of homelessness, move on from Stage 3 and have sufficient independent living skills to work towards an independent lifestyle , have a housing related supp ort need and be willing to engage with the landlord & support provider. Creative Support provide housing related su pport to clients with a range of support needs. Support will include (but not be limited to) support with finances, healt h / well-being, build & sustain links with families/support networks and transition from supported living into independ ent living where Creative Support will continue to support service users.

DRYDEN ROAD (WESTCLIFF), DN17 1PQ - Dryden Road Housing Management is provided by Sanctuary Housing including the Health and Safety of the building, rent payments and dealing with day to day issues on site. The support is provided by Creative Support who provides a supported service to clients with a range of support needs to enable them to sustain their tenancies. Support will include (but is not limited to) support around finances, health and wellbeing, build and sustain links with family and support networks, support the transition from supported living into independent living where Creative Support will continue to support the service user on a pathway to independence.

PLEASE INDICATE USING BOXES PROVIDED WHICH ACCCOMMODATION PROJECT YOU ARE APPLYING FOR. DO NOT TICK ALL AS THE APPLICATION WILL NOT BE ACCEPTED AND WILL BE RETURNED. YOU CAN APPLY FOR STAGE 2 AND STAGE 3 AT THE SAME TIME DUE TO DIFFERENT LEVELS OF SUPPORT. 1. PERSONAL INFORMATION SURNAME: FORNAME:

ETHNICITY: GENDER:

CURRENT ADDRESS or C/O ADDRESS N.I. NUMBER

CONTACT NUMBER:

Email address (if applicable) Reason for application –

PLEASE EXPLAIN WHY SUPPORTED ACCOMMODATION IS NEEDED.

If yes please give details Are you currently homeless? If yes, please give details and state how long you have been homeless Yes No for Are you or have you ever had any support from Social Services or any other agency. Yes No

Are you a care leaver? Yes No

Are you registered for social housing with housing Yes No providers including Home Choice Lincs. Active If yes is your application active or suspended Suspended Don’t know 2. ADDITIONAL INFORMATION If yes please give details Do you require any help understanding English or Yes No need an interpretation service? The supported accommodation provider must operate to an equality and diversity policy. Would you Yes No have any problems or issues with adhering to the policy? The supported accommodation provider may utilise both volunteers and students in the delivery of its Yes No services. Would you be happy for a volunteer or student to be involved in the delivery of your support? Have you been a member of the Armed Forces (of any country)? Yes No

3. CHILDREN AND CHILD PROTECTION If yes please give details Are you pregnant? If yes, please state your estimated due date. Yes No N/A

Do you have any children? Yes No N/A If yes, do you have any children who:

 You are responsible for or have custody of  Have been supported by Social Services (Social Care  Have spent time in a Social Services care Yes No N/A placement  Are on the ‘at risk’ register / on a child protection plan  Have been Involved in the common assessment framework

Who does your child/children reside with?

What contact arrangements do you have in place?

4. YOUR HEALTH If yes please give details Do you have any alcohol or substance misuse Yes No issues either current or past ? Do you consider yourself to have a physical disability? Yes No

Are you a wheelchair user, or do you have any mobility needs? Yes No

Do you have a visual or hearing impairment? Yes No

If yes do your need or have assistance with this Yes No Have you been diagnosed with any long term illnesses? Yes No

Have you been diagnosed with a mental health condition? Yes No

Do you have a learning disability? Yes No

Do you have any other health conditions? Yes No

5. FINANCE If yes please give details Do you have any income from employment / Yes No benefits / maintenance / savings?

Have you ever been evicted? Yes No

Do you have any housing benefit arrears? Yes No

Do you have any outstanding debts; include rent arrears, fines, loans, recharges for damages to Yes No property etc?

6. CAUTIONS OR CONVICTIONS – Please list ALL cautions and convictions including arson, sex offences or any violent behaviour (attach a separate sheet if necessary). Nature and Date of caution or conviction Further details

Please give dates / details of any custodial sentences

Please give details of any pending court appearances

Are you under an Anti-Social Behaviour order? If yes please give details.

Are you subject to a Sex Offenders Prevention Order (SOPO)

Do you have any court injunctions against you? If yes please give details. Are there any injunctions in place for your protection? If yes please give details.

7. Other agencies involved. Please list agencies that applicant is currently open to AGENCY DETAILS: CONTACT NAME AND TELEPHONE NUMBER: 8. RISK ASSESSMENTS – PLEASE ATTACH CURRENT RISK ASSESSMENT

RISK TO APPLICANT :

(PLEASE TICK) LOW MED HIGH DON’T KNOW RISK TO STAFF :

(PLEASE TICK) LOW MED HIGH DON’T KNOW RISK TO OTHERS :

(PLEASE TICK) LOW MED HIGH DON’T KNOW

9. SUPPORTING INFORMATION

PLEASE ENSURE THIS SPACE IS USED TO PROVIDE ADDITIONAL INFORMATION TO SUPPORT THE APPLICANT

Continue on a separate sheet if necessary 8. REFERRER DETAILS

Agency: Contact Name:

Job Title:

Contact Number:

Length of time involved with client: Email Address:

To be signed by referrer: By signing this form you are declaring that all Referrer signature: information you have provided on it is accurate at to the best of your knowledge. If inaccurate or incomplete information is provided this may result in Date: your service user’s application being rejected.

9. APPLICANT CONSENT

To be signed by the applicant: 1) I (the applicant) hereby give my authority for any We may need to contact other agencies for relevant agency to disclose information for the information so we can process your application. purpose of dealing with my application for This could include other housing providers, the supported accommodation. I understand that this probation service or social services. The applicant information is to be used solely in relation to my agrees to this by signing the following statements application and will not be disclosed to any other persons without my permission.

2) The details I have given in this application are true and correct. I understand that if I have knowingly given any false information or withheld information about my application this may result in my application being rejected.

Applicant signature :

ALL APPLICATIONS ARE PRIORITISED ON A NEEDS BASIS