This form is to help you tell us about the support and assistance you need in your everyday life.
You may choose to complete this on your own or you may find it helpful to ask another person to support you. On submission of your form, we will look at the information you have provided and decide if we need to contact you again, usually by telephone, to gather more information.
The information you provide will help us to identify your current level of need and aspects of daily living where you may be having difficulties.
All referrals will be treated confidentially and are subject to data protection legislation and the Freedom of Information Act.
Please note, parts of this form may not be applicable to your situation.
How long have you lived at this address?
Please tell us about your health, medical conditions and/or disabilities. Please provide medical documentation to support this.
Where appropriate we will share information with other organisations including the local authority social care, health and the fire service (who provide fire safety checks and advice if it is felt this would be of benefit).
Medical priority is only given in cases where a person’s medical condition is serious enough that their present home is unsuitable for them and that a move to another property would ease or improve the issues being experienced.
here to view our policy