Title

First Name

Last Name

Date Of Birth

Age

National Insurance Number

Address Line 1

Address Line 2

City/Town

County

Postcode

Phone number

Mobile number

Email Address

Next of Kin

Next of Kin Contact Number

Gender

Ethnicity

Religious Beliefs

Disability

Sexual Orientation

Marital Status

First Language Spoken

Pregnancy & Maternity Status

Referrer Name

Agency/Organisation

Referrer Job Title

Relationship to Referrer

Referrer Address

Referrer Phone number

Referrer Email Address

Do you receive any benifits? YesNo

Which forms of idea do you possess? Driving licencePassportBirth CertificateHome Office letter stating indefinite leave to remainOther Please note proof of ID will need to be provided at the Panel Assessment

Have you ever been evicted? YesNo

Are you aware of any arrears for rent or housing benefit? YesNo

Does another person manage your finances? YesNo

Housing history

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.)

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Current Accommodation Bed & BreakfastPrivate RentedHousing AssociationOwner OccupierCouncil TenantPrisonHospitalHomelessTemporary AccommResidential HomeStaying with family/friendsSheltered HousingSupported HousingDetox / Rehab

Other

Please describe any issues with current accommodation (e.g. Rent arrears, anti-social behaviour, eviction order, pests, damp etc.)

Support Needs

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

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GBH/Wounding (Section 18 or Section 20 Offences Against the Person Act) YesNo

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Any sexual offence against a child(ren) YesNo

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Rape or serious sexual offence against an Adult YesNo

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Any other offence against a child YesNo

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Aggravated Burglary YesNo

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Arson YesNo

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Criminal Damage with Intent to Endanger Life YesNo

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Kidnapping/False Imprisonment YesNo

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Possession of a Firearm with Intent to Endanger Life YesNo

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Racially Motivated or Racially Aggravated Offence YesNo

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Robbery YesNo

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Any offence involving possession and/or use of weapons YesNo

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Assaulted/Threatened staff YesNo

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Assaulted/Threatened others YesNo

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Been violent towards a partner, family member or any other person with which they have lived with YesNo

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Committed a serious offence whilst not complying with medication YesNo

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Been sentenced to 4 years imprisonment or more YesNo

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Been involved in any hate based behaviour YesNo

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Been assessed as a High Risk of Harm YesNo

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Been a conditionally discharged patient subject to a restriction order under Section 41 MHA 1983 YesNo

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Received an Extended Sentence YesNo

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Displayed stalking behaviour (whether convicted or otherwise) YesNo

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Displayed obsessive behaviour linked to offending YesNo

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Bizarre or ritualistic behaviour linked to offending YesNo

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Acted inappropriately towards staff or other visitors/service users YesNo

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Been involved or suspected involvement in gang activity/organised crime YesNo

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Indecent Images, Stalking, Harassment etc. YesNo

Name of Responsible Officer

Responsible Officer Email Address

Telephone Number

Is the applicant in Custody? YesNo

Any Local Area Exclusion Zones YesNo

Please provide details of the applicants history and pattern of offending (e.g. summary of previous convictions, repeat victimisation/targeting, triggers or disinhibitors to offending etc).

OGRS 2 Year Reconviction Score

Risk of Harm Assessment LowMediumHighVery High

Please give details of any other agencies involved in the management and support of the applicant

Name of Support Worker name

Contact Details (email and/or telephone)

Name of Support Worker name

Contact Details (email and/or telephone)

Name of Support Worker name

Contact Details (email and/or telephone)

Name of Support Worker name

Contact Details (email and/or telephone)

Name of Support Worker name

Contact Details (email and/or telephone)

Name of Support Worker name

Contact Details (email and/or telephone)

Name of Support Worker name

Contact Details (email and/or telephone)

Name of Support Worker name

Contact Details (email and/or telephone)

Name of Support Worker name

Contact Details (email and/or telephone)

Referrer Name

Referrer Signature (Input name)

Date

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.

Applicant Name

Applicant Signature (Input name)

Date

Please double check the application before submission. Any errors in the application may delay the process taking longer than expected.

Once happy, click submit below