Borders CHOICE•HOMES www.homehunt.info Borders Choice Homes Specific Need to be in a Community Application Form Priority for a Specific Need to be in a Community is awarded at Bronze level. You may qualify for Bronze Priority if: You need to move to a specific area to provide or receive care and support You are having difficulty accessing essential services Before applying for a priority in this category please check that your need to be in a community is not covered by one of the other priority. For example if you need to move to a community to receive care and support you can complete a Unified Health Assessment Application. In order to assess your Specific Need to be in a Community Priority application, please complete form in full. APPLICATION BCH Registration Number Name:_____________________________________________________________ Address ______________________________________________________________________________ ______________________________________________________________________________________ Telephone: Home ____________________Work____________________Mobile_____________________ How long have you lived at your current address: ____ years ____ months Previous address:_______________________________________________________________________ _______________________________________________________________________________________ Why did you leave your previous address:_________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Do you have access to a car that you can drive: YES NO Do you need to move to access essential services: YES NO What type of services do you require to access and how often: Do you need to move to provide / or receive support? YES NO Please provide details of support: Relationship to you_______________________________________________________________________ Name _________________________________________________________________________________ Address _______________________________________________________________________________ Telephone ______________________________________________________________________________ What type of Care and Support are you able to provide:___________________________________________ _______________________________________________________________________________________ Please sign here _____________________________________Date_______________________ I confirm that the information I have given is correct and that I have not supplied any false or misleading information. I agree to the use of this information in accordance with the data protection notice as stated in the ‘Guide to Borders Choice Homes’ booklet. PLEASE TICK WHICH AREAS YOU WOULD LIKE YOUR PASS TO COVER You must apply for ALL suitable properties in the areas chosen or your priority will be removed after 6 months (please see the BCH Guide Booklet for more information on priority) Coldstream Area Eyemouth Area Galashiels Area Cont. Kelso Area Birgham Ayton Lauder Heiton Coldstream Cockburnspath Melrose Kelso Eccles Coldingham Newstead Morebattle Gordon Eyemouth Deanhead Newtown St Boswells Stichill Greenlaw Eyemouth Gunsgreen St Boswells Town Yetholm Hume Eyemouth Old Town Tweedbank Leitholm Foulden Peebles Area Swinton Burnmouth Hawick Area Broughton Whitsome Grantshouse Bonchester Bridge Cardrona Hutton Denholm Eddleston Duns Area Lower Burnmouth Hawick Burnfoot Innerleithen Allanton Paxton Hawick Central Peebles Chirnside Reston Hawick Silverbuthall/ Skirling Cranshaws St Abbs Stirches West Linton Duns Upper Burnmouth Hawick West End Walkerburn Gavinton Hawick Wilton Longformacus Galashiels Area Newcastleton Selkirk Area Preston Clovenfords Bowden/Lindean Westruther Earlston Jedburgh Area Ettrickbridge Stow Ancrum Lilliesleaf Galashiels Central Jedburgh Selkirk Galashiels /Langlee/ Oxnam Yarrowford Haliburton Galashiels Torwoodlee Sheltered Housing Developments If you have indicated a Sheltered Housing Requirement on your registration, please tick to choose the Developments you wish your pass to apply to. Coldstream, Gowanea Court Hawick, Douglas Haig Court Duns, Boston Court Hawick, Frank Scott Court Eyemouth, Linkim Court/Swan Court Hawick, Teviot Court Galashiels, Abbotsford Court Melrose, Millar House Galashiels, Oakwood Park Peebles, Riverside House .