Lighthouse Application Form

  • Lighthouse Application Form

    Please complete the form below to apply.

  • Applicant Contact Details

  • Date of Birth*
     - -

  • Additional Contact Person

  • Family & Living Circumstances of Applicant

  • Marital Status*
  • Accommodation*
  • Are you currently on benefits?*

  • Health

  • How would you describe your personal health?*
  • Do you have any physical impairment, chronic disease or disability*
  • Do you require assistance with daily activities as a result of any impairment?*

  • Substance Misuse

  • Do you use alcohol?*
  • Do you use drugs?*
  • If yes, do you inject?*
  • Do you require a medical detox?*
  • Rows
  • Are any of the above prescribed to you?

  • Mental & Emotional Health

  • Have you ever experienced mental or emotional health problems?*
  • Have you ever seen a psychiatrist?*
  • Are you currently under psychiatric care?*

  • If yes, please give details of your Community Psychiatric Nurse/Psychiatrist

  • Have you ever been in hospital as a result of mental or emotional health problems?*
  • Are you prescribed any medication for mental or emotional health issues?*
  • Rows
  • Have you ever had an eating disorder and/or have been know to self harm?*

  • Past Offences

  • Do you have a criminal record?*
  • Have you spent time in prison?*
  • Do you have any outstanding warrants*
  • Do you have any outstanding court appearances*
  • Have you ever been prosecuted for any violent offences?*
  • Have you ever been prosecuted for any sexual offences?*
  • Have you ever been prosecuted for arson?*
  • Are you subject to any statutory supervision or probation?*

  • If yes, please give details of your Supervisor/Probation Officer

  • Personal Statement

  • Reference 1 of 2

  • Reference 2 of 2

  • Consent and Declaration

  • In order to make a decision about your admission to The Lighthouse it may be necessary to contact workers or agencies that have been involved with you. We will only contact people with your permission and any information received will be treated as confidential.

    It should be remembered, however, that to process your application you must complete all the information requested on this form. The application process could be delayed if we are unable to liaise with other workers. To complete your application it may be necessary to share information given during your assessment with other relevant services.

  • Date of Birth*
     - -

  • I give The Lighthouse permission to act on my behalf regarding my benefits and acquire any information concerning my history from my doctor throughout the duration of my programme.

  • I also give my consent for the staff from The Lighthouse to obtain written and/or verbal information about me from the following people for the purpose of assisting in my assessment.*

  • I have completed this application form truthfully and to the best of my knowledge. I understand that any misleading information could jeopardise my entrance to The Lighthouse or remaining apart of the The Lighthouse.

  • Date*
     - -
  • Should be Empty: