PLEASE NOTE: Please complete this form in
full. If incomplete, we’ll return it to the applicant.
Guidance notes
1
• Risk assessment
• Care or Support plan (i.e. care programme approach)
• Other information that may help your application
• A passport-sized photo. (Photographs will be kept on our system and used to verify your identity.)
P
lease complete all sections of this form. We may not be able to consider your application for
housing if you do not.
If a particular section doesn’t apply to you, please write “not applicable” or N/A.
Please ensure that you sign and date the form on page 11.
If you need help completing this form, please contact us on 01582 869 320.
If you’d like to send us this form electronically, please email it to:
supported.housing@peabody.org.uk
Please note we’re unable to accept applications for supported housing from joint applicants.
Please return your completed form to Supported Housing team, Peabody, 6 Houghton Hall Business Park,
Porz Avenue, Houghton Regis, Bedfordshire LU5 5UZ or email to: supported.housing@peabody.org.uk
www.peabody.org.uk
Email
Organisation
If you have completed the form on someone else’s behalf please ensure that the applicant has signed the
‘To be signed by you’ section, or conrm that they have given their consent.
Telephone Name
Address
When returning your form, please enclose the following information covering the last 12 months:
If you are completing the form for someone else please enter your contact details below:
Application for
supported housing
Applicant
2
How long have you lived here?
Please tick appropriate box
Private rented
Sharing with family or friends
Tenancy with local council
Temporary accommodation
Owner occupier
Tenancy with housing association
Homeless
Other
Landlord name and address (if applicable)
What type of accommodation do you live in at the moment?About you:
Female Transgender
Is your gender now the same as it was at birth?
Yes No Prefer not
to say
Title (e.g. Mr/Mrs/Miss)
First name
Last name
Address
How long have you
lived at this address
Home telephone
Mobile telephone
Work telephone
Home email address
Work email address
Date of birth
National Insurance
Number
Gender Male
Section 1 - About you
33
Are you a member of Peabody staff or board, or
related to a member of Peabody staff or board?
If yes, please give details
Please list your addresses for the past five years – Please continue on a separate piece of paper if needed
Current and past addresses
Yes No
Address
Type of accommodation
E.g. living with family, renting with a private
landlord. If you were renting from the council or
housing association please state which one.
Were you evicted from this
accommodation?
If you have answered “yes”, please give details
4
Do you use a wheelchair?
If you cannot understand a tenancy agreement, does someone else have legal authority to sign on your behalf,
such as power of attorney or court of protection order?
What type of housing would you prefer? (Please tick all that apply.)
To live on your own To share with other people To live somewhere with staff onsite during the day
Do you have any pets?
If yes, please give details. (Please be aware that depending on the type of property or area you are moving to,
in some cases it may not be possible for your pet to be re-housed with you)
Yes No
Do you have any current or previous rent arrears?
If yes, please give details.
Yes No
Have you been evicted from any previous
accommodation?
If yes, please give details.
Yes No
Yes
No
Do you need any special equipment or adaptations?
If yes, please give details.
Yes No
If yes, please give details.
Yes No
Section 2 - Your housing needs
5
Do you consider yourself to have an impairment or disability that affects your day-to-day life?
Drugs and alcohol
We ask the following information so we can match you with the most suitable service.
Physical impairment or mobility issues such
as difculty using arms, or using a wheelchair
or crutches
Mental health difculty such as depression,
schizophrenia or anxiety disorder
Specic learning difculty such as dyslexia
or dyspraxia or ADHD
A mild, moderate or severe learning disability?
(Please specify in the box below.)
Other impairment, health condition or learning
difficulty that is not listed above (S
pecify in the box
below if you wish.)
Prefer not to say
Do you require support to enable you to manage your
tenancy?
Yes No
Do you currently use illegal drugs, or have you used them
in the last six months?
Yes
No
If you answered yes, please provide details of the specialist drug and alcohol service that supports you with this.
Yes No
Do you drink alcohol?
How much alcohol do you drink each week?
If you answered yes
, who supports you?
Units
Section 3 - Other information
Your support needs
Convictions
Comments
Employment, benefits and money
We ask the following information for reasons of safeguarding and assessing risk.
If you’re not eligible for funding, are you prepared to
pay directly for the support you require?
What’s your current employment status?
Have you ever had a conviction for a violent offence?
Yes
No
Have you ever committed arson?
Yes
No
Working more than 30 hours
a week
Unemployed
Self Employed
Other – please specify
Retired
No
We ask the below questions to assess affordability and check that you’re getting all the benefits you’re entitled.
Do you currently receive any benefits? Yes
If yes, which of the following benefits do you currently receive?
6
Housing Benet
Income Support
Job Seekers Allowance
Employment Support
Allowance (ESA)
Retirement Pension
Pension Credits
Guarantee
Savings
Attendance Allowance
Working Tax Credits
Universal Credit
Disability Living Allowance
Mobility
Care
(Please state
rate received.
)
Low mobility
High mobility
Low care
Mid care
High care
Other – please specify
Personal Independence
Payment (PIP)
Daily Living Component
Standard rate
Enhanced rate
Yes No
Do you have savings over £6,000?
Section 3 - Other information continued
Yes No
7
Your support contacts
We may need to make further enquiries in connection with your application for housing. If you receive support or help
from any of the following professionals please provide us with their contact details. We will only make contact if we need
information that is relevant to your offer of housing with us. Any information provided will be treated in the strictest
con
dence. By providing us with these details, and signing the following page, you are giving consent for us to contact the
people you have listed.
Doctor
Psychiatrist
Probation officer
Social worker
Community nurse
Interpreter
Support worker
Name
Name
Name
Name
Name
Name
Name
Address
Address
Address
Address
Address
Address
Address
Phone
Phone
Phone
Phone
Phone
Phone
Phone
8
Please tell us your ethnicity below. Providing this information allows us to check that people from different groups
are accessing our services equally. You don’t have to tell us if you’d prefer not to and it won’t affect your chances of
being housed.
Ethnic origin
White
Mixed
British
English
Scottish
Welsh
Northern Irish
Irish
Irish traveller
Romany
Gypsy
Other
White and Asian
White and
Black African
White and
Black Caribbean
Other
Asian or
Asian British
Black or
Black British
Other
ethnic group
Prefer not
to say
Bangladeshi
Indian
Pakistani
Other
African
Caribbean
Other
Arab
Chinese
Other
Nationality
UK national resident in the UK
UK national returning from
residence overseas
Bulgaria
Croatia
Czech Republic
Estonia
Hungary
Ireland
Latvia
Lithuania
Poland
Slovakia
Slovenia
Romania
Other European Economic
Area (EEA*) country
Any other country
Prefer not to say
*EEA countries are: Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Greece, Iceland, Italy, Liechtenstein,
Luxembourg, Malta, Netherlands, Norway, Portugal, Spain, Sweden and Switzerland.
9
Religion or belief
No religion
Atheist
Buddhist
Christian*
Hindu
*Christian includes Church of England, Catholic, Protestant and all other Christian denominations
Jewish
Muslim
Sikh
Other
Prefer not to say
Heterosexual (Straight)
Bisexual
Homosexual (Gay/Lesbian)
Sexual orientation
We have asked you to tell us your religion and sexuality as this may be important when responding to problems people
have, for example, harassment. This information is also used to ensure fair treatment for all residents and to check that
everyone is accessing our services equally. We do appreciate this may be sensitive information and you can choose not
to answer if you prefer.
Other
Prefer not to say
Communication
Large print
Braille
Communication
Do you have any specific communication requirements? (Please tick all that apply.)
Pictorial/easy r
ead format
Audio translation
Sign language
If English is not your first or preferred language, are you able to? (Please tick all that apply.)
Write English Read English
Speak English
If English is not your preferred or first language, please tell us which language is:
10
The introduction of Universal Credit has moved the application for claiming some benets online. We are also working
to improve our online services to customers. Knowing how many people use the internet, and how condent they are in
doing so, will help us with this.
Please tick below which one of the following statements you feel most applies to you:
If you do use the internet, how do you access it? (please tick all that apply).
Which of the following methods would you prefer us to contact you by? (Please tick all that apply.)
We will do our best to contact you by your preferred method but there may be some cases where we have to
contact you in a certain way, for example by letter for some rent arrears.
Communication
Phone
Email
Text Message (SMS)
Letter
In person
I use the internet regularly and
am condent using it
I have access to the internet but
need some help using it
I do not have access to the internet
but would like to use it
I do not have access to the
internet and do not want to use it
At home
At work
On a mobile device such as
tablet or smart phone
Other e.g. library or job centre
Emergency contact
Emergency contact
This should be someone who does not live with you. It may be a friend, neighbour or family member, but they must give their
consent to be contacted in an emergency. We will use this information if we need to contact you in an emergency and are
unable to.
Telephone
Relationship to you
Has the person you have nominated given their consent to be contacted in an emergency? If yes, please tick here
Name
Address
Enquiries on your behalf
If you would like to give someone else permission to be able to discuss matters with us on your behalf, please complete the
details below:
Have the people listed above given their consent for you to give us their details? If yes, tick here
Name Relationship
to you
Password
(e.g. authorised
person’s date of birth.)
Telephone Organisation
(if applicable.)
Catalyst may wish to make further enquiries in connection with my application. This information may include details
concerning my medical and social history and I give consent for the appropriate professionals, familiar with my housing
and support needs, to release such information as is thought necessary. I understand that all information will remain
confidential and will not be passed on without my permission. However, I also understand that ifany of the below incidents
they may have to pass this information on to a manager in their team or another relevant agency without my consent.
• Someone who is seriously hurting me or another person
• Someone who has seriously hurt me, or another person, in the past
• Something I have done to seriously hurt another person
• Any illegal activity I am committing.
11
Safeguarding
Data protection
We take our data protection responsibilities seriously. We collect, store and process data in line with data protection law.
Peabody Trust ('Peabody') is the Data Controller for the personal information that you give us on your customer information
form. This means that we’re the people responsible for deciding what to do with it and for keeping it accurate and up-to-date.
We use your information to manage your relationship with us, including to determine your tenancy application, to provide
services to you under your tenancy agreement and to provide support services at your request.
We have set out all the ways in which we use your information and details of any third parties that we may transfer your
information to in our Privacy Notice. You can find a copy of this on our website at: peabody.org.uk/terms-conditions/privacy
If you have concerns about how we are dealing with your data, in the first instance, you should raise these with the
Customer Hub or your key contact within Peabody. If you are not satisfied with their response you can contact the Group
Data Protection Officer at [email protected]
You can also write to us: 45 Westminster Bridge Road, London SE1 7JB.
To be signed by you
Joint applicant
Signature
Signature
As far as I know, all the information I have given is true and correct. I understand that providing false information may lead
to my application being refused, or to me losing my home if I have already taken on a tenancy. I agree to Peabody making
further enquiries that may be necessary in connection with this application for housing.
I understand that the information I have provided on this form will be used to assess my eligibility for housing, and that
it may be passed to other housing organisations and other third parties to try to assist me in obtaining accommodation. If I
accept a tenancy with Peabody I understand that the information provided here will form part of my tenancy records. If I
accept a tenancy with Peabody I understand that my details may be passed on to the utility suppliers to assist with any
billing queries during and at the end of my tenancy.
I agree to inform Peabody of any changes to the information I have provided here. I understand that I can ask to see the
information that is held about me at any reasonable time.
First applicant
Name
Name
Date
Date
12
Peabody
6 Houghton Hall Business Park
Porz Avenue
Houghton Regis
Bedfordshire
LU5 5UZ
01582 869100
www.peabody.org.uk
If you’d like to receive this information in
another format please contact 0300 500 6262
or email [email protected]
