Medway Council Health And

MEDWAY COUNCIL HEALTH AND COMMUNITY SERVICES

Shared Lives Initial Application Form

MEDWAY COUNCIL Shared Lives – Initial Enquiry Form

1. Personal Details

Applicant 1 Applicant 2

Name: …………………………… Name: …………………………..

D.O.B D.O.B

Address ………………………… Address …………………………….. ………………………………………. ………………………………………. ……………………………………….. ……………………………………….. ………………………………………. ……………………………………….

Tel No: Tel No: Daytime: ……………………….. Daytime: ………………………….

Evening: ………………………. Evening: ………………………….

Mobile No……………………………………………………

Email Address ……………………………………………..

1. How long have you lived at your current address? ………………………………….

2. Are you living together as a couple / married? Yes / No

3. Are you interested in offering a long-term placement? Yes / No

4. Are you interested in offering short breaks? i.e. (weekends or weeks only). Yes / No

5. Are you interested in offering Kinship Support ? Yes / No

6. Are you interested in offering Day Support? Yes / No

7. Have you applied to any other schemes in the past? Yes / No 8. Other people in your household:-

Name: D.O.B Relationship to you:

All applicants will be expected to attend a Preparation Course. The times and dates will be forwarded to you shortly.

Signed ………………………………………….. Date …………………………

Signed …………………………………………. Date ………………………..

Please complete and return to :-

Shared Lives Lordswood Community & Healthy Living Centre Sultan Road Lordswood Chatham, Kent ME5 8TJ

Telephone: 01634 337100

Please tell us where you heard about Shared Lives: