Thistle Housing Medical Appliaction

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