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ApplicantDetails
Equality &Diversity
ReferrerDetails
ID &Income
Housing &Tenancy
SupportNeeds
HarmScreening
Risk ofReoffending& Harm
OtherAgencies
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Please provide a complete history of your / the applicant’s housing history covering the last 5 years. Please include temporary housing, hospital admissions, prison sentences, homelessness etc. For ‘Type of accommodation’ please specify (private rental, B&B, staying with friends, living with family, hostel, hospital, prison, local authority, housing association etc.)
This section is one of the most important as it helps us to understand how best we can support the applicant whilst residing with us and helps us to consider which of our properties would best support their rehabilitation.
Support Need Accommodation (e.g. lack of move on accommodation)Drug MisuseETEAlcohol MisuseMoney & DebtThinking & Behaviour (e.g. poor problem solving, poor emotional control etc.)Relationships (e.g. DV history, family issues, child contacts etc.)Attitudes (e.g. Pro-crime attitudes, discriminatory beliefs etc.)Lifestyle & Associates (e.g. boredom, easily influenced, criminal peers etc.)Health (e.g. physical support needs, mental health issues etc.)
Please provide details relating to all of the need areas identified
Do you have any mobility concerns? YesNo
Are you happy to share facilities such as a kitchen/bathroom with men? YesNo
Do you consider yourself to be suitable for home visits by a lone female worker YesNo
Please identify any relevant risk indicators below including details about the behaviour and any protective factors that mitigate the level of risk.
Have you / the applicant ever been convicted of…
Murder, Attempted Murder, Conspiracy to Murder or Manslaughter YesNo
GBH/Wounding (Section 18 or Section 20 Offences Against the Person Act) YesNo
Any sexual offence against a child(ren) YesNo
Rape or serious sexual offence against an Adult YesNo
Any other offence against a child YesNo
Aggravated Burglary YesNo
Arson YesNo
Criminal Damage with Intent to Endanger Life YesNo
Kidnapping/False Imprisonment YesNo
Possession of a Firearm with Intent to Endanger Life YesNo
Racially Motivated or Racially Aggravated Offence YesNo
Robbery YesNo
Any offence involving possession and/or use of weapons YesNo
Assaulted/Threatened staff YesNo
Assaulted/Threatened others YesNo
Been violent towards a partner, family member or any other person with which they have lived with YesNo
Committed a serious offence whilst not complying with medication YesNo
Been sentenced to 4 years imprisonment or more YesNo
Been involved in any hate based behaviour YesNo
Been assessed as a High Risk of Harm YesNo
Been a conditionally discharged patient subject to a restriction order under Section 41 MHA 1983 YesNo
Received an Extended Sentence YesNo
Displayed stalking behaviour (whether convicted or otherwise) YesNo
Displayed obsessive behaviour linked to offending YesNo
Bizarre or ritualistic behaviour linked to offending YesNo
Acted inappropriately towards staff or other visitors/service users YesNo
Been involved or suspected involvement in gang activity/organised crime YesNo
Indecent Images, Stalking, Harassment etc. YesNo
What is the nature of the risk?
When is the risk likely to be greatest?
What factors are likely to reduce the risk?
Please give details of any other agencies involved in the management and support of the applicant
Children’s Services / Adult Social Care
Mental Health Worker / CPN / Psychiatrist
Counsellor
Drug / Alcohol Worker
Operational Partner
Voluntary / Charity Organisationr
Other
Applicant Consent:
I give consent for the information contained herein to be shared with other agencies for the purpose of assessing and addressing my housing and support needs.
I give consent for the referrer to obtain and provide further information, some of which may be special category information regarding any criminal or social/medical history from relevant agencies regarding my support needs.
I understand that Reactive8 Housing may enquire and seek further information appropriate to my application for housing and give consent for the appropriate professionals, familiar with my history, housing and support needs to release information about what is deemed necessary and appropriate to my application upon request. I understand that I can withdraw my consent for Reactive8 Housing to access and/or share personal information related to me at any time upon making a written submission to this effect. I understand that withdrawing consent to access and/or share information will invalidate any Licence Agreement that I may have entered with Reactive8 Housing and that any offer or supply of accommodation will be withdrawn.
Once happy, click submit below