Supported Accommodation Referral – Norman Galloway Forms

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Supported Accommodation Referral

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- Step 1 of 11

About you the proposed applicant...

Proposed Applicant Name *

First

Last

Please tell us the first line of your address including house number? *

Date of Birth *

What are your preferred pronouns? *

He/him
She/her
They/them

Which country are you from? *

Select the ethnicity that best describes you. *

If you have selected 'Mixed or multiple ethnic groups' or 'Other', please provide further details. *

Which language/s do you speak? *

Do you follow any religion? If so, which one? *

What town do you live in? *

What is your postcode? *

Please tell us details about where you live, or where you previously lived and why you are applying for Supported Accommodation at Norman Galloway Homes? *

Proposed Applicant Phone Number *

Support Worker / Personal Advisor *

First

Last

Support Worker / Personal Advisor Email *

Support Worker / Personal Advisor Phone Number *

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About your experience in prevous supported accommodation...

Have you ever been in Supported Accommodation before? *

Please give further details here? When was this? Where was this? How did you get on? *

Did you experience any rent arrears in your previous accommodation? *

Yes
No
Don't know

Have you ever been evicted or asked to leaver from previous supported accommodation? *

Please describe the circumstances if you have had rent arrears or have been evicted or asked to leave from supported accommodation? *

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About the supported accommodation that Norman Galloway Homes provides...

We provide various types of supported accommodation... please select all that are appropiate for you. *

Shared accommodation 16+
Shared accommodation 18+
Solo accommodation 16+
Solo accommodation 18+
Asylum seeking children 16+
Asylum seekers leaving care

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Appointments

Are you registered with a doctors general practice? *

Do you need help in registering with one? *

Please, provide the name of your GP and a full address. *

When did your last appointment take place? *

Are you registered with an opticians? *

Do you need help in registering with one?

Please, provide the name of your opticians and a full address. *

When did your last appointment take place? *

Are you registered with a dentist? *

Do you need help in registering with one? *

Please, provide the name of your dentist and a full address. *

When did your last appointment take place? *

Is there anything on your last Health Assessment that we should know about to able us to support them? *

Do you have an appointed solicitor? *

Please, provide full details to your solicitor. *

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About any disabilities you may have?

Do you have any disabilities?

Yes
No
Prefer not to say

Please tell us which disability you have?

Autistic spectrum condition
Hearing impairment
Learning disability
Mental health
Mobility
Progressive / chronic illness
Visual impairment
Wheel chair user
Other

About your physical health?

Do you have any physical health problems?

Yes
No
Prefer not to say

Please tell us what physical health problems you have?

Breathing problems or chest pain
Cancer
Dental problems
Diabetes
Epilepsy
Eye problems
Fainting / blackouts
Hypertension
Liver problems
Poor foot health
Problems with bones, joints and muscles
Problems with circulation / blood clots
Respiratory
Skin / wound infection
Stomach pain or problems
Urinary problems / infections
Other
Other - do not want to disclose

About your mental health?

Have you in the past or do you struggle now with your mental health?

Yes
No
Don't not want to dislcose

And when have you struggled with your mental health?

This is ongoing
Previously in the last 12 months
Over 12 months ago
Do not wish to disclose

Please tells us about your mental health struggles now or in the past

Aggressive or violent towards others
Difficulty sleeping
Feel depressed
Hard to control anger
Hear voices
Often feel anxious
Often feel stressed
Panic attacks
Self harm
Suicidal thoughts
Other
Do not with to disclose

Do you self-harm or have you self-harmed in the past or struggled with suicidal thoughts?

Yes
No
Prefer not to say

Do you use drugs or alcohol to cope with your mental health?

Yes
No
Prefer not to say

What support would help with your mental health

Activities - arts / volunteering / sport
Medication
Peer support
Practical support with daily life
Service to address dual diagnosis
Specialist mental health worker
Talking therapies e.g. counselling
Something else

Please tell us about any other support that you get or that would help with your mental health?

Do you have a mental health diagnosis?

Yes
No
Do not wish to disclose

Please tell us about any diagnosis that you have?

ADHD
Anxiety disorder
Asperger’s
Autism
Bipolar disorder
Depression
Dual diagnosis - drug / alcohol problem
Eating disorder
Personality disorder
Phobia
Post-traumatic stress disorder
Schizophrenia
Tourettes
Other mental health diagnosis
Do not wish to disclose

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About any involment with the police or criminal justice system?

Please tell us about any involvement you have ever had?

Had involvement with the police
Has has a reprimand or warning
Involved with probation
Involved with youth justice
Unspent criminal convictions
Spent criminal convictions
Subject to MAPPA arrangements
Served a community penalty
On licence
Have ever served a prison sentance
None of these
Other

Please tell me in your own words what happend? *

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About your education, training, employment and volunteering

Your current economic status

Full time student
Full time work (over 24 hours per week)
Government training or work program
Job seeker
Long term sick / disabled
Not seeking work
Part time work (under 25 hours per week)
Part time work (zero hours contract)
Other

Please tell us in your own words about your work history

Please tell us in your own words about your education?

Please tell us in your own words about any training you have done?

Please tell us in your own words about any volunteering you have done?

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About any substance use

Do you have any drug or alcohol addictions? *

Are you currently getting medication because of your addictions? This could be from your GP, or drug and alcohol services and mental health services. Are you engaging with other services? *

What medication and services are you engaging with? *

What (non-Prescribed) drugs are you taking, and how much alcohol are you drinking daily. *

Please tell us about their self-harming? When was the last time and what happend? *

What substances do you use or have used in the past?

Alcohol
Amphetamine / Speed
Benzodiazepines / benzos
Cannabis / weed
Crack / cociane
Heroin
New psychoactive
Prescription drugs
Other

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About your living skills

How would you rate yourselft with money, paying bills and budgeting?

Selected Value: 0

Where 0 is you find this really difficult and really need help and 10 is where you don't need any help whatsover.

Please tell me why you rated yourself with that score for money, paying bills and budgeting? *

And please tell us what help you may need to improve your money skills? *

How would you rate yourself with cleanliness, hygiene, cooking and general house work?

Selected Value: 0

Where 0 is you find this really difficult and really need help and 10 is where you don't need any help whatsover.

Please tell me why you have rated yourself with that score for cleanliness, hygiene, cooking and general house work? *

And please tell us what help you may need to improve their cleanliness, hygiene, cooking and general house work skills *

How would you rate yourself with how you use your time? Is this in a meaningfull way? Such as work, training, volunteering?

Selected Value: 0

0 is where you really need help and motivation to spend your time more positively and 10 is where you don't need any help or motivation whatsoever.

And please tell us what you normally do with yourself from day to day?

And is there something you would really like to start doing that would improve your mental health?

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About our supported accommodation

We operate a no visitor policy for the first month in our supported accommodation as we would like to monitor how your progress is. Would that be an issue for you? We will explain more about this later) *

Please tell us why you would have issues with a no visitors policy in the first month? *

As part of the licence agreement with Norman Galloway homes you will have to engage with our support worker weekly. Would you agree to that and be able to adhere to this? *

Why would you not be able to engage with a support worker at least weekly? *

As part of Norman Galloway supported homes, we will regularly do welfare and room checks at the property will this be an issue to you? *

Why would you have an issue with welfare and room checks? *

Have you ever been evicted or had issues with anti-social behaviour where you have previously lived or have you been violent towards staff or other people. *

Please can you give us further details about previous anti-social behaviour? *

Norman Galloway supported homes has a no smoking policy inside the property do you believe you can adhere to this? *

Why could you not stick to a no smoking policy? *

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We would like to discuss this application with you and the person that is helping you. This person could be a firend, relative, social worker, personal advisor or any other person.

I give permission to discuss my application with a 3rd party
I DO NOT give permission to discuss my application with a 3rd party
Don't know

Please tell us who you give us permission to talk to about your application.

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Name

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