APPLICATION/ASSESSMENT FORM FOR SUPPORTED ACCOMMODATION AT TACT FRHP
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1 APPLICATION/ASSESSMENT FORM FOR SUPPORTED ACCOMMODATION AT TACT FRHP These questions are not an examination you have to pass, we merely need to know about you so we can be sure we can offer you the support that you require. However, please note that if this form is not completed honestly with full details of you medical/using/contact history, it may lead to a termination of your tenancy. The recovery programme is expected to take between 6 24 months to complete. Date... SECTION 1 (Referrer details) Referred from Contact name ephone SECTION 2 (Applicant details) Full name.. Current address... M/F DOB // ephone... NINO.. Religion If your current address is a treatment centre, rehab, detox unit, prison, probation hostel or any other not your home address, please give your home address If accepted when would you want a place?......
2 Please state your ethnic origin. Do you consider yourself to have a disability? Are you registered as disabled? Client Group by which the client is defined Substance misuse - alcohol Substance misuse - drugs Single homeless with addiction support needs Mental health problems with addiction support needs Offenders or at risk of re-offending Women exiting prostitution People with HIV/AIDs Rough sleeper Complex needs.. Primary (only tick one with x) Secondary (tick a max of three) Any other information? SECTION 3 We will need to speak with any other agencies/professionals involved in your care and well-being. Are you agreeable to this? Please tell us about people/organisations/professionals involved Source of referral Please tick 1 below LA Housing Department Prison / Probation / Police DIP Team Voluntary Agency Solicitors Moving from another RSL Health Service/GP Social Services Other Self Referral
3 Social Worker Care Worker Probation Officer..... Other Name.... Next of Kin.. Relationship..... SECTION 4 Are you currently in receipt of benefits? If so, which benefit/s do you receive? How often do you receive your benefit? How much do you receive, in total? If not, how will you pay for your stay with us? If you are currently in employment, what is your income? SECTION 5 Are you currently taking any medication? Yes/ No Illegal drugs / nonprescribed medication?
4 If yes, what? SECTION 6 All our accommodation operates a policy of total abstinence from any drugs, chemicals and alcohol (except prescribed) as the primary requirement for residence. Do you agree to abstain completely (except prescribed medication)? We carry out random testing for drugs and alcohol. Do you agree to provide a sample of saliva swab / breathalyser if required? How long have you been drug free?.. Alcohol free? What are your views on total abstinence from all mood altering drugs/chemicals/alcohol?..... SECTION 7 Do you have any physical disabilities?.. Are you registered as disabled?.. Is there anything in this section for which you would require any specialist treatment or specially adapted aids in the accommodation?.. Have you ever been diagnosed as suffering from any mental health conditions such as schizophrenia, psychosis, manic depression or any other? Food disorders such as anorexia, bulimia or any other?
5 Do you have any specific needs relating to anything in this section? SECTION 8 Have you ever been diagnosed as suffering from HIV, Hepatitis A, B or C or similar conditions? of your ongoing treatment and/or medication Any other illness that is infectious or likely to put you or anyone else at risk? Are you currently awaiting any test results for any of the above in this section? SECTION 9 Have you ever self harmed? Please tell us specifically what you have done to harm yourself When was the last time?. SECTION 10
6 Have you ever been charged with or convicted of a sexual offence?.. Have you ever been charged with or convicted of arson?.. If in custody will you be leaving on license and will you need to be licensed to our address? Yes/No.. SECTION 11 Have you ever been charged with or convicted of any other crimes?.. SECTION 12 Please tell us about your previous or ongoing treatment and/or medication for anything else not detailed in the above sections SECTION 13 Do you have a current partner? Do you have any dependent children If so how many, and their ages: Do you pay child care costs?
7 SECTION 14 What is your main motivation for change? We are a peer-led support service offering group support and key working support meetings and you are required to fully participate in our recovery programme. Do you agree to this? Section 15 Self - Sufficiency Are you self-sufficient in managing: Finances Medication Shopping / Cooking Personal Care SECTION 15 Is there anything else you would like to tell us? DECLARATION All the information I have given in the above sections 1 to 15 is a true record. I understand fully that if I am offered support and accommodation then later any of the information I have given is found to be inaccurate or false it may lead to my residency being terminated immediately. I have read the attached in-house agreement and understand that when taking up a place at The bridge I will be also entering into this agreement. I have read the terms of this agreement and would be happy to sign such an undertaking at the commencement of my tenancy should a place be offered to me
8 Signed Print name Date... This form must be filled in by the applicant except in the case of literacy difficulties. If this is the case, please declare herewith. Form filled in by Position/Relationship to Applicant... Please note that if false information is given by a third party, then this too may lead to the residency being terminated immediately. Please return the completed form to Sam Phipps TACT Female Recovery Housing Project Strickland House, The Lawns, Wellington, TF1 3BX : sam.phipps@tacteam.org.uk
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