Homeless Assessment Form

I acknowledge that Worcester City Council will process and store my information in accordance with Data Protection Law. For more information, please see our privacy notices on our website. *

Title *

Forename *

Surname *

Where did you stay last night? (please include address) *

Do you have somewhere to stay tonight? (including with friends and family) *

Have you been given notice to leave your home? If so, please state the expiry date of the notice (i.e. the date you have to leave by) *

Have you been asked to leave where you have been staying (e.g. by family or friends)? If so, please state the date you have been asked to leave by. *

National Insurance Number *

Date of Birth *

Nationality *

Current Address *

What date did you move into this address? *

Previous Address

Would you consider yourself to have a disability? *

Yes

No

If yes please give details of your disability *

Do you have a serious, ongoing medical condition? *

Yes

No

If yes please give details of your medical condition *

Are you known to the Community Mental Health Team? *

Yes

No

If yes, who is your case worker? *

Have you been released from a custodial sentence within the last month? *

Yes

No

If yes, please state the date you were released from prison *

Are you on a rehabilitation order or probation order? *

Yes

No

If yes, please provide details *

Are you recently discharged from the Armed Service and/or have you been a member of the Armed Forces? *

Yes

No

If yes, please provide details *

Have you ever been in care? *

Yes

No

If yes, name the authority that placed you *

Number of dependent children under the age of 16? *

Are you expecting a baby? *

Yes

No

If yes, please give due date *

Have you approached Worcester City Council Homeless or Advice before? *

Yes

No

If yes, please provide details *

Are you registered on Home Choice Plus? *

Yes

No

What is your local connection to Worcester City (i.e. you live, work or have immediate family in the city)? Please be specific - i.e. include addresses, names and relationship to you or state no connection. *

Please enter the details of your current enquiry. Please note the more details you can provide us with will enable us to deal with your enquiry quickly.

Please indicate whether you can be contacted by phone. If you do not have a telephone number we can contact you on, please select 'No'. However you must then go to The Hive to see a housing officer as we will not be able to contact you. When you speak to a member of staff at The Hive please advise them that you have already completed this online form.

Do you have a telephone number we can contact you with? *

Yes

No

Telephone number *

You have indicated that you cannot be reached by phone. You must go to The Hive to see a housing officer as we will not be able to contact you. When you speak to a member of staff at The Hive please advise them that you have already completed this online form.

Email

Where are you completing this form? *

Homeless Assessment Form

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