Clone of Householder Application Form

Householder Enquiry Form
This quick form takes about 2 minutes.
It helps us understand what kind of support would be most helpful and how to contact you.
Householder's Contact Details
Householders Name*

First NameLast Name
Householder Phone Number
e.g. 07123 456789
Householder E-mail
example@example.com
Householder Postcode*

Street Address

Street Address Line 2

Town/CityCouncil Area (Optional)

(This helps us confirm the area you’re in)
Who is filling out this form?

I am the householderI am completing this form on behalf of the householder (family / friend)
Primary Contact Details
Your name (who is filling out this form)*

First NameLast Name
Contact Phone No.*
e.g. +44 7123 456789
Contact E-mail*
example@example.com
Relationship to the Householder (optional)
Permission confirmation

I have the Householder’s permission to share this information and submit this enquiry.
Householder Preferences
What kind of support would be most helpful?

Friendly company / someone to chat toReassurance of someone else in the homeHelp with light chores (tidying, laundry, small tasks)Help with shopping or errandsCooking support / shared mealsHelp with a dog / pet careTech help (phone, TV, laptop)A bit of structure / routine during the weekOvernight presenceOther
Would you be happy to live with a :

MaleFemaleCouple
When do you think you might like this support to begin?

As soon as possibleIn the next 1–2 monthsIn the next 3–6 monthsJust exploring for now
Is there anything else you’d like us to know before we call?
How did you hear about us?
Please Specify
Finally, may we add you to our Homeshare Scotland newsletter? (Opt out at any time)

Yes
Should be Empty:

Householder Enquiry Form

Householder's Contact Details

Primary Contact Details

Householder Preferences