Application Form

First name

Last name

Email

Phone

Date of Birth

Gender

Current Address

Previous Address

Language and Interpreter

Preferred Language

Other

Current Living Status

Living Status

Homeless

Pending Homelessness

Please share as much details as possible

Marital Status

Clients Current Marital Status

Dependants

Does the client have any dependants?

Yes

No

Referrer's Details

Name of Referrer

Referrer Organisation

if Other is selected, please state referrer organisation

Referrer Oranisation Location

Phone No.

Email

The Responsibility of Referrers

In order to achieve our common objective of helping customers with their housing needs, we are dedicated to cultivating an open and efficient collaboration.

Please be advised that failing to provide all pertinent information during a referral may result in referrers being flagged for further consideration, which could negatively affect how well our client support system works.

Extra Support Needs

Does your client have Care, Support or Supervision Needs, please select all that apply

Care

Support

Supervision

None of the above

Please provide a detailed description of your Clients support needs

Income

National Insurance Number

Benefit Status

Benefit Receiving or applied for

Other Income Source

Please provide as much detail as possible regarding benefits and income

Next of Kin

Next of Kin Name

Next of Kin Relation to Client

Next of Kin Telephone

Social Worker and Additional Services

Please select all that is applicable. 'My client has a....'

Social Worker

Community Psychiatric Nurse

Hospital Consultant

Psychiatrist

Client Assessment

The service users at Neron will receive the best possible care. In order for the panel to determine whether this is the best service for your client, we are depending on your feedback in the following part regarding your assessment of the client's support needs.

Does the client have a history of, or a diagnosis for, any of the following ?

Medical Conditions

Yes

No

Mental Health Conditions?

Yes

No

Misuse of Drugs?

Yes

No

Misuse of Alcohol?

Yes

No

Has your client been abstinent for 8 or more weeks?

Yes

No

Does your client struggle with social interaction in any way?

Yes

No

Details of any associated Risks

Offending History

Does your client have any history of offending, past or present?

Yes

No

If Yes, please upload all relevant documents.

Please provide a comprehensive history of offenses and a risk assessment, if applicable.

Is the client currently participating in Integrated Offender Management (IOM)?

Yes

No

Client Assessment, Continued

Risk to Self

Risk to others

Risk to Property

Proof of ID

3 Months' Bank Statement's

Proof of Benefits

Referrers Declaration

By clicking Submit, I declare that the information provided on behalf of my client is accurate and correct.

I understand that any intentional misinformation may result in the rejection of this application or the immediate termination of placement with

NERON RESETTLEMENT HOMES CIC