Medical Priority Application Form
APPLICATION
Application for medical priority housing supplied by Thistle Housing Association
APPLICATION FOR MEDICAL PRIORITY Please read this form carefully and answer every section. There may be some questions, which do not apply to your circumstances. You should ignore these and go to the next question. Your application will not be processed unless ALL relevant sections are completed. The information given will be treated in the strictest confidence, however, you should note that we will require to take up references. When complete return the form to us at: 26 Glenmore Avenue, Toryglen, Glasgow, G42 0EH. Telephone: 0141 613 2700 If you have any difficulties with this form, please contact the office.
1. PARTICULARS OF PERSONS WHOSE NAMES WILL APPEAR ON THE TENANCY DOCUMENTS Title (Mr, Mrs, etc.)
Title (Mr, Mrs, etc.)
Surname:
Surname:
Forename:
Forename:
Address:
Address:
Post Code:
Post Code:
Date of Birth:
Date of Birth:
Home Telephone No:
Home Telephone No:
Work Telephone No:
Work Telephone No:
Applicant Reference No:
2. PARTICULARS OF PERSONS APPLYING FOR MEDICAL PRIORITY Title (Mr, Mrs, etc.) Surname:
Post Code:
Forename:
Date of Birth:
Address:
Home Telephone No: Work Telephone No:
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Thistle Housing Association: Medical Priority Application
3. YOUR HEALTH YOUR HEALTH: How would you describe your health or mobility difficulties and how long have you had them? Health or Mobility Difficulties
How long have you had these difficulties Years Years Years
Months Months Months
YOUR HOME: How do your health or mobility difficulties make your present accommodation unsuitable?
MEDICINES: Are you currently receiving medication for your conditions? (Please copy the names from the containers)
OTHER TREATMENT: Are you receiving any other treatment for your condition?
ARE YOU REGISTERED BLIND?
Yes
No
ARE YOU REGISTERED DISABLED?
Yes
No
DO YOU RECEIVE ANY DISABILITY BENEFITS? (eg. Incapacity Benefit, Disability Living Allowance etc)
Yes
No
If yes, which
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Thistle Housing Association: Medical Priority Application
(Please tick appropriate box)
HOSPITAL: Have you been admitted to hospital recently?
Yes
No
(Please tick appropriate box)
Yes
No
(Please tick appropriate box)
If yes, give the following details: Reason for admission Length of stay Name of Hospital Name of Hospital Doctor CLINIC: Are you attending a clinic? If yes, which
4. YOUR MOBILITY WALKING: Do you have difficulties walking? (please tick appropriate box) NO YES, can only walk short distances YES, unable to walk If you have ticked yes, do you use any of the following? (please tick appropriate box) Walking Stick
Wheelchair (Indoors)
Walking Frame
Wheelchair (Outdoors)
Crutches
Other, Please specify
CLIMBING STAIRS: Do you have difficulty climbing stairs? (please tick appropriate box) NO
YES, requires a great effort
YES, takes time
YES, totally unable to climb stairs
If you have ticked YES, how many stairs can you manage?
USING BATHROOM: Do you encounter difficulty using the bath or toilet in your home? (please tick appropriate box) NO
YES, I use special aids YES, I need help
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Thistle Housing Association: Medical Priority Application
Do you receive regular help or assistance from any of the following: Name
Telephone No. (if available)
Address
Relative Friend Social Worker Home Help District Nurse Health Visitor Occupational Therapist Voluntary Organisation Other Briefly describe the assistance being given:
5 . CURRENT ACCOMMODATION YOU PRESENTLY OCCUPY Please supply details of ALL persons presently occupying current home, starting with yourself. Name
Date of Birth
Relationship to Applicant
Sex - Male/Female
Self
TYPE OF ACCOMMODATION: Details of accommodation you presently occupy (please tick appropriate box) Cottage
Flat within close
Maisonette
4-in-block flat
Multi-storey
Floor level
How many bedrooms are in your home? Single
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Thistle Housing Association: Medical Priority Application
Double
STAIRS: Number of stairs: Stairs up to
If yes, indicate the number of Stairs
Front Door
Yes
No
Back Door
Yes
No
Your Bedroom
Yes
No
The Toilet
Yes
No
The Bathroom
Yes
No
HEATING: What type of heating system does your current home have? (please tick appropriate box) Electric fire only
Electric storage heating
Gas fire only
Gas central heating
Other, please specify Does your heating system or ventilation cause any problems?
Yes
No
Yes
No
Yes
No
Yes
No
If YES, describe them
Does the house you currently occupy suffer from dampness or condensation? If YES, please supply a letter from your Landlord verifying this. Has your current home been adapted in any way because of your health or mobility difficulties? If YES, what adaptations were done? If your house could be adapted to suit your medical condition would you prefer to stay in your home?
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Thistle Housing Association: Medical Priority Application
6. OTHER INFORMATION What type of accommodation do you think best suits your needs? (please tick appropriate box) Single-storey
Terraced end
Multi-storey
Flat within close
Terraced mid
Semi-detached
Sheltered
What is the highest floor level you could accept?
7. OBTAINING FURTHER INFORMATION What is your family doctor’s name?
Name Address
Telephone No:
If you get regular support from anyone else (such as a District Nurse, Community Psychiatric Nurse, Occupational Therapist, Hospital Consultant), please give their name and address below.
Name Address
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Thistle Housing Association: Medical Priority Application
In order to assess your health priority for re-housing a report from a health or social work professional or from a voluntary service or other Housing Provider may be requested. Your consent for this form to be copied to them and for them to give us relevant information to help in this health assessment is required.
Please detail below any other information which you feel may be relevant to your application.
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Thistle Housing Association: Medical Priority Application
8. DECLARATION BY PERSON CLAIMING MEDICAL PRIORITY I/We have read and understood this application form and I/We hereby certify that all the information I/We have given is correct. I/We understand that any false or misleading statement or withholding of relevant information now or at any subsequent date, will result in the application being cancelled. I/We also give Thistle Housing Association permission to discuss the information with the appropriate housing, social work and medical staff to assist in assessing this application. I/We understand that all information will be treated as strictly confidential and only be available to those who need to see it to assess my health priority.
Signature:
Date:
Signature:
Date:
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Thistle Housing Association: Medical Priority Application
26 Glenmore Avenue, Toryglen, Glasgow G42 0EH Tel: 0141 613 2700 Fax: 0141 613 2727 Email: admin@thistle-ha.org.uk