ࡱ>  }bjbj .{{, , ooC?H' .BDLND(GGGGGGGILGQvD<J.BvDvDGoo GBEBEBEvD@ob  GBEvDGBEBEFGnG ԟVDj^GGH0?HfG M E" MnG MnG$BEvDvDvDGGBEvDvDvD?HvDvDvDvD MvDvDvDvDvDvDvDvDvD, 5: TcAc Housing and Support Panel Young Persons Application Form What type of accommodation or support is required? Please number in order of preference i.e.; 1, 2, 3 etc Single Accommodation Shared Accommodation  Shared living with other  A flat for someone living alone with young people and Housing Support and staff women only  Supported Carers (LSCS) Shared living with other young people and staff mixed  Care leavers flat scheme  Shared living with other  young people and a mentor Housing support in your own tenancy A flat with other young people and staff  A farm setting with other young Is there any type of accommodation you would people and staff/volunteers Not consider, if so please say below:  Other Young Persons Details First NameSurnamePreferred Name GenderDate of BirthTelephone Number Male Female  SHAPE  Name of Referring Worker and contact details (including e mail address): Address Current Accommodation  Staying with friends/family YPC  Hostel B & B Residential Unit  Foster Care Temp Accommodation  Other. Main Language English Other ..Please specify:  FORMTEXT       Interpreter needed?  FORMCHECKBOX  No  FORMCHECKBOX  YesInterpreter required Yes No If Yes which language & & & & & & & & & & & & .. Please specify: FORMTEXT      Household members seeking accommodation with you Adults Children Name Date of Birth Relationship to you ....................... .. . .. .  Key Contacts Please tell us about anyone who is currently working with you and providing support (including social worker, if you have one). Please also provide details of referring worker. Please indicate if you agree to us contacting the person should further information be required. NameAgencyContact number Permission to contact   Yes/No   Yes/No   Yes/No  Source of Income What are your sources of income?How much do you receive?How often do you receive this? Where will the money come from to pay for your accommodation? (You may need to check this with your social/support worker)  Education/Training Please provide details of any training or education you are doing at present: or have recently applied for: Health Disability/Health Needs (you or anyone moving with you)  No Yes Please specify: FORMTEXT      Please specify:  FORMDROPDOWN  S23/24 Assessment?  FORMCHECKBOX  No  FORMCHECKBOX  YesIf yes, how would this be affected by where you are housed? (ie floor level etc) Are you pregnant? Yes No Due Date . Accommodation/care placement history Please provide information on any previous tenancies or care placements:  SHAPE  Reason for moving Please say why you wish to move on from your current address  Support Needs What type of support do you think you need? Please indicate if you think you need help with any of the following Housing Support Needs Other Support Needs  Benefits/TCAC Payments Education/Training/work  Cooking/Healthy Eating Offending Behaviour  Managing money/budgeting Substance Misuse Keeping safe/gatekeeping Health Issues Help with correspondence/forms Other  SHAPE  Are there any areas you would prefer to live? Please give reasons why  Are there any areas where you cannot live? Please give reasons why The information contained in this application will be shared with the accommodation and support providers listed in the guidance notes. 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