Apply For Housing First Name *Last Name *National Insurance Number *Phone Number *Email Address *Date of Birth *Month *Day *Year *Gender *SelectMaleFemaleOtherAre you currently pregnant? *Are you currently pregnant?YesNoMaybeNot ApplicableWhat is your full current address? *Postcode of your current address? *Select Ethnicity *SelectWhite BritishWhite IrishWhite OtherAsian British IndianAsian British PakistaniAsian British BangladeshiAsian British OtherArabIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black, Black British, or Caribbean backgroundMixed or multiple ethnic groupsWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or multiple ethnic backgroundEnglish, Welsh, Scottish, Northern Irish or BritishIrishGypsy or Irish TravellerRomaAny other White backgroundOther ethnic groupPlace of Birth? *Sexual Orientation *SelectHetrosexualHomoSexualStraightGayLesbianPrefer Not to sayOtherMarital Status *SelectSingleAmrriedOtherReligion *SelectNo Religion/AthiestIslamHinduChristiancatholicBuddhismSikhPrefer Not to sayOtherCommunication Needs *SelectSpare RoomLarge PrintBrailleAudiotape/CDBSL/MakatonTranslation/InterpreterOtherPlease provide the full name of your Next of kin. *What is the full address of your Next of kin? *What is your relationship with your Next of Kin?SelectParentSpouseSiblingSon/DaughterFriendOtherNext of kin's phone number? *What is your current living situation? *Selectliving with parentsOtherWhy do you want to move from your current accommodation? *What was the last address you claimed Housing Benefit from? *When did that housing benefit start? *Month *Day *Year *Please tick your preferred areas *SelectLadywoodEdgabastonStockland GreenKingstandingErdingtonHandsworthBartley GreenHall GreenNorth FieldAcocks GreenYardleyWinson GreenStech FordSpark HillSmall HeathSelly OakPerry BarMoseleyAre you on the Birmingham City Council waiting list for housing? If yes, how long? *How long have you been living in Birmingham? *Please state all criminal convictions (if any) including dates and time served. *Do you have any S1 or Arson offences? (Please provided as much detail as possible) *If you are on probation, please state the officer's details and when the order ends. *Do you have any alcohol or drug uses (past or present)? If so, please detail how often and which drugs. *Do you have any mental health issues? *Do you have any physical health issues? *Detail all medication being taken (including methadone script). *Do you have any debts? If so, please provide details. *Do you have any issues with gambling? If so please provide details. *Do you have any other conditions you think you have to make us aware of? *Do you have contact with any other external support teams? *SelectYesNoAre you engaging with support so far and/or are you willing to cooperate further with our support services?SelectYes I have no Issues with itI may find this difficultPlease tick all the areas of support that you feel apply to you... Please note this is supported housing and so if you have no support needs, unfortunately, we wont be able to house you. *SelectTenancy failure or losing short-term accommodationBecoming homeless/evicted (within 28 days)Ongoing issues with drug and alcoholAbility to manage ongoing health problemsAccess to local services Rough SleepingAccess to health servicesImproved quality of lifeBuild an alternative support networkSkills to eat healthilyAccess voluntary servicesAbility to manage personal hygieneRisk of domestic abuseIncrease social and community networksFrequent presentation to accident and emergencyUnplanned hospital admissionsReduce social isolationIncreased feelings of being more independentAbility to manage health & wellbeingAbility to manage finances betterDeveloping interpersonal skillsIncreased knowledgeIncreased confidenceAccessing drug and alcohol servicesObtaining or maintaining a suitable homeHave you ever served in the British Armed Forces? If yes, have you ever been injured/disabled from doing so? *How would you describe your status? *SelectReceiving BenefitsLooking for WorkUnable to WorkWorking (Over 16 Hours)Working Parttime (Less than 16 Hours)Self EmployedInterested in EducationOtherWhat benefit do you receive? *SelectUniversal CreditESAPIPState PensionOtherHow much are you receiving and how often?When is your next payment due? *Month *Day *Year *What is the name and or location of your benefit office? *Please note, there is a service charge of £17.50 per week to stay at a Walking Waters Supported Housing, we ask that this be paid 4 weeks in advance. This would mean that we would require £70 on the day you move in. *SelectI understand and this is OK.I can pay this if I want to take a roomI understand this. but may struggle to pay all in advanceI am not willing to pay service charge to stayLastly, We need to be very clear that this is supported housing. You must engage in the support sessions, which will be at least 1hr per week. Please confirm this is the correct service for you. *SelectI understand and have no issues engaging in weekly support sessionsI really need accommodation but don't want to engage with the supportI don't really like the idea of engaging with the supportDid someone refer you to us? Please enter their name below so we can thank them!Proof of Benefits Without proof of benefits we will not be able to offer you a placement.Please add your most recent statement here or send it via email/WhatsApp before your viewing. *Choose FileNo file chosenDelete uploaded filePhoto ID. Please add a clear picture of your ID here or send it via email/WhatsApp before your viewing *Choose FileNo file chosenDelete uploaded fileSubmit
