YMCA Exeter Supported Housing Application
ABOUT YOURSELF
Applicant Name
*
First Name
Last Name
If you have ever been known by another name, please state it here:
Applicant Phone Number
*
Applicant Email
*
example@example.com
If you are currently staying at a permanent address, please state below:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived in Exeter?
If less than 6 months, where did you live before?
Date of Birth
-
Day
-
Month
Year
Date
Describe your gender
Please Select
Male
Female
Transgender
non-binary
prefer not to say
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What is your marital status?
Please Select
Single
Married
Widowed
Separated
Divorced
Registered partnership
Number of children
If you have any children, are you responsible for their care?
Please Select
Yes
No
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YOUR PRESENT CIRCUMSTANCES
Details of your present Landlord
We will not contact any person/s you give details of without your consent.
Name
First Name
Last Name
Contact Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of accommodation (if rough sleeping, please indicate below)
Reason for leaving or needing to leave:
Details of your previous Landlord/ Housing provider:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Why did you leave this accommodation?
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YOUR PRESENT ECONOMIC/WORK SITUATION
Education
We will not contact any person/s you give details of without your consent.
Are you currently in education?
Please Select
Yes
No
Which college/university did you attend/are you attending?
Name of Tutor:
Email address of tutor
example@example.com
Contact Number of tutor
example@example.com
Full or Part time?
Full time
Part time
Work
We will not contact any person/s you give details of without your consent.
Are you currently working?
Please Select
Yes
No
Name of Company:
Name of Line Manager:
Email address of Line Manager
example@example.com
Phone Number of Line Manager
Current salary or hourly pay
How frequently are you paid?
Weekly
Fortnightly
Four weekly
Monthly
Between work/education/training
Are you receiving Benefits? If so, please tick all that apply
Universal Credit
Housing Benefit
JSA (Job Seeker's Allowance)
PIP (Personal Independence Payment)
DLA (Disability Living Allowance)
Other
Benefit Income (please specify individual amounts for each benefit you are receiving)
How frequently are your benefits paid to you?
Fortnightly
Monthly
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You and YMCA Exeter
Who referred you to YMCA Exeter/told you about us?
Exeter City Council or Devon County Council
Social Services
Another housing association
We called you, following a homeless prevention panel meeting
Probation services
Family or friend
YES Centre
Self-referral
Other
Name of your Housing Adviser at YES Centre or Exeter City Council:
Their contact details (if known)
Do you know anyone who lives, or has lived, at YMCA Exeter?
Yes
No
If yes, please give their name(s):
Please tick which YMCA Exeter accommodation you would like to be considered for:
1st Choice
2nd Choice
Stage 1: St David's Hill
(31 bed hostel close to Exeter Central Station and Exeter St David's Station. You have your own room with kitchenette, shared bathroom and shared lounge. Staff are there weekdays from 9am-10pm and weekends 2pm-10pm)
Stage 2: Newcourt
(4 bed shared houses near Exeter IKEA. You will have your own bedroom, shared bathroom, shared lounge and shared kitchen. Staff are around most weekdays and some evenings. They are only present at the weekend for emergencies)
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Do you have any medical conditions we might need to know about in an emergency (e.g. asthma, diabetes, epilepsy, allergies)?
Yes
No
If yes, please give details:
Are you on any medication?
Yes
No
If yes, please give details:
Do you have any physical disabilities?
Yes
No
If yes, please give details:
Do you have any learning disability (e.g. ADHD, dyslexia)
Yes
No
If yes, please give details:
Do you require, or have you required in the past, special help exiting a building in an emergency (e.g. a fire)?
Yes
No
If yes, please give details:
Do you have an adult social worker? If yes, please complete the details below:
Yes
No
On waiting list
Social Worker Name:
Social Worker Telephone:
Social Worker Email:
example@example.com
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Emotional/Mental Health Needs
We will not contact any person/s you give details of without your consent.
Have you ever suffered from depression, anxiety, mood swings or similar?
Yes
No
Have you ever suffered from an eating disorder?
Yes
No
Have you ever harmed yourself in any way?
Yes
No
If you have answered yes to any of the above questions, please provide any detail below:
Do you have a Mental Health Worker If yes, please complete the details below:
Yes
No
On waiting list
Mental Health Worker Name:
Mental Health Worker Telephone:
Mental Health Worker Email:
example@example.com
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Dependencies
We will not contact any person/s you give details of without your consent.
Have you ever had an alcohol problem or dependancy?
Yes
No
Have you ever had a drug problem or dependancy?
Yes
No
Have you ever misused solvents (glue, gas, lighter fuel, etc)?
Yes
No
Have you ever gambled?
Yes
No
If you have answered yes to any of the above questions, please provide any detail below:
Do you have a Support Worker? If yes, please complete the details below:
Yes
No
On waiting list
If yes, which agency?
Support Worker Name:
Support Worker Telephone:
Support Worker Worker Email:
example@example.com
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Dependencies
How often do you drink alcohol? Please give details of type, frequency and amount
How often do you use illegal drugs? Please give details of type, frequency and amount
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Criminal History
We will not contact any person/s you give details of without your consent.
Have you ever been cautioned of a criminal offence? (including spent convictions)
Yes
No
Do you have any court appearances pending?
Yes
No
Are you on probation or a youth offending order?
Yes
No
Do you have any history of arson?
Yes
No
Do you have any history of violence or antisocial behaviour?
Yes
No
If you have answered yes to any of the above questions, please provide any detail below:
Do you have a Support/Probation/YOT Worker? If yes, please complete the details below:
Yes
No
On waiting list
If yes, which agency?
Name:
Telephone:
Email:
example@example.com
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References - please provide two professional references
People who can give a reference for you (e.g. line manager, tutor, counsellor, support worker, social worker - or any other person you have been in contact with in a professional capacity)
First Referee:
Name:
*
Relationship to you:
Agency/Organisation:
Telephone:
*
Email:
*
example@example.com
Second Referee:
Name:
*
Relationship to you:
Agency/Organisation:
Telephone:
*
Email:
*
example@example.com
If you can't provide two professional references, please provide a personal reference:
If you do not have any support agency working with you, please give details of someone else who can give a reference for you (preferably not a family member):
Name:
Relationship to you:
Telephone:
Email:
example@example.com
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Declaration
The facts I have put down on this form are true and complete to the best of my knowledge. I will inform YMCA Exeter at once if the facts change so that my application can be kept up to date. I understand that any false or misleading statement may mean that my application is rejected without right of appeal. Should I be given accommodation with YMCA Exeter on the basis of false or inaccurate information, my licence agreement may be terminated.
Signature
Print name here
First Name
Last Name
Authorisation
In the course of processing your application for supported accommodation at YMCA Exeter may need to contact people and/or agencies you have had contact with in order to obtain information about you, including information that you may have given to them in confidence. Similarly, we may need to ask them to verify certain information that you have given in the course of the application process. They will normally be willing to give us this information, provided that you give your authorisation. Any information we receive in this manner will be treated with the strictest confidence within YMCA Exeter staff team and management committee. To speed up the application process, it can be helpful for information about you to be shared between YMCA Exeter and other supported, housing providers that you have applied to. This includes references and risk assessments. If you are not willing for this information to be shared in this way, please call 01392 410530.
I hereby authorise that relevant information related to my support service and accommodation at YMCA Exeter may be passed between YMCA Exeter and the following:
Exeter City Council (Housing Benefit), Devon County Council (Support Commissioner), Department for Work and Pensions (Job Centre), Social Services, Probation Services & Youth Offending Teams, Substance Misuse Services, Youth Enquiry Service, and any of the agencies or people I have mentioned on my application form or I may mention at any other time of the application process.
If there are any agencies/people mentioned in your application that you do not authorise us to contact, please state their name below:
Do you agree and understand that disclosure of my information may include a risk assessment
Yes
No
On waiting list
Are you happy for your references to be shared with other supported housing projects that I may be applying to (*mark box to indicate).
Yes
No
Do you authorise Exeter City Council to disclose information regarding any housing benefit debt you may owe, or any housing benefit dispute you may be involved in?
Yes
No
On waiting list
Do you authorise YMCA Exeter to notify my referral agency (if applicable) of the outcome of your application and the reasons for this outcome?
Yes
No
Do you also authorise YMCA Exeter to request information from the police in order to provide information towards a risk assessment with regards to my application?
Yes
No
Signature
Print name here
First Name
Last Name
Date
-
Day
-
Month
Year
Date
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Equal Opportunities Monitoring
Please select below the option that best describes your ethnic origin:
(a) White
British
Irish
Other
(b) Mixed
White and Black Caribbean
White and Black African
White and Asian
Other
(c) Asian/Asian British:
Indian
Pakistani
Bangladeshi
Other
(d) Black/Black British:
Caribbean
African
other
(e) Other ethnic group (please specify):
Sexuality:
Heterosexual (straight)
Homosexual (Gay/Lesbian)
Bi-sexual
Prefer not to say
Other
Religion:
Christian
Muslim (Islam)
Jewish
None
Other
Do you consider yourself to have a disability?
Yes
No
Prefer not to specify
Submit
Should be Empty: