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Gloucestershire Housing Assessment Form
Gender
Male
Female
Client Code (see guidance notes for how to write this)
Date
Ethnic Origin - please state if 'other'
Age Group
16 - 17
18 - 19
20 - 24
15 or under
25 - 35
36 - 45
46 - 59
60+
Completed by
Last Settled Place of Residence
Referred From
Primary reason for seeking advice/ assistance
Household Type
Couple with children
Single
Seperated Parent
Single Parent
Couple
Guardian
Type of Disability
Sensory
Physical
Mental ill health
Learning
Does the client consider a member of the household to have a disability?
Yes
No
Number of dependent children
Current Circumstance
Status Today
Income
Incapacity Benefit
Training Allowance
Attendence Allowance
Income Support
Wages/ Earnings
Child Benefit
Job Seekers Allowance
Disability Living Allowance
NIL
Pension
Other
Housing Benefit
Housing Needs Priority - NB: if the client has an HNP, the client must be referred to the local authority
Dependent children
Leaving Institution
Physical Disability
Former Care Leaver
Mental illness
Victim of violence
Homeless Due To Emergency
Vulnerable Elderly
Move on
Learning Disability
Pregnant
Young Person (16/17) not in care
Leaving armed forces
Support currently being provided to the client
Probation Officer
GYHA
CAB
Rethink
Health Visitor
Connexions
School/ College
Housing Aid Centre
County Community Projects
Social Worker
Knightstone
CPN
Soulutions
Floating support
Next Step
Tenancy Support
Occupational Therapist
GDAS
YOS
GDVSAP
Prevent & Deter
Support requested by the client
Alcohol
Family mediation
Physically disabled
Fleeing violence
Benefits Advice
Tenancy support
Frail elderly
Debt/ Money problems
Training/ Job
Learning disabled
Drugs
Translation Services
Literacy/numeracy
Education
Emotional difficulties
Mental health
Agency/ Agencies you have referred the client to
ELIM
ASTRA
Stonham
Bromford
Forest of Dean DC
Stroud DC
CAB - Chelt. & Tewkesbury
GEAR
Tier 3 - YHAS
CAB - Cirencester
Tier 4 - YHAS
CAB - Gloucester
Tewkesbury BC
CAB - Forest of Dean
Gloucester CC
YMCA
CAB - Stroud
GLOS PCT
Cheltenham BC
Glos.Part.NHS.Found.Trust
Youth service
GRIP
Connexions - Cheltenham
Victim Support
Connexions - Cotswold
Connexions - FOD
HOMEVIEW
Connexions - Gloucester
NIGHTSTOP
Connexions - Stroud
PIP
Connexions - Tewkesbury
Cotswold DC
Probation
Refuge
CHYP
C&ACD
Shelter
C&YPD