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Housing Assessment Form

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SECTION A: PERSONAL INFORMATION

Full Name: *

Date of Birth: *

Gender: *

Male
Female
Other

Other:

National Insurance Number: _ *

Phone Number: *

Email address *

Current Address: *

SECTION B: REFERRAL INFORMATION

Referrer Name: *

Referrer Contact: *

Date of Referral: *

SECTION C: HOUSING SITUATION

Length of Time in Current Situation: *

SECTION D: SUPPORT NEEDS

If other or, please specify your support need *

SECTION E: CURRENT PROFESSIONAL INVOLVEMENT

If Yes, please specify:

SECTION F: RISKS & SAFEGUARDING

SECTION G: INCOME AND EMPLOYMENT

Type / Monthly Income: £

Do you receive Housing Benefit or Universal Credit? *

Yes
No

SECTION H: HOUSING PREFERENCES & NEEDS

Preferred Location(s):

Gender Preference (if any) for accommodation: *

No Preference
Male only
Female only

Shared Living Experience *

Comfortable
Not comfortable
Requires own space

Any accessibility/adaptation needs? *

Yes
No — If yes, provide details below

SECTION I: CONSENT & DECLARATION

Applicant Signature (Tick) *

I understand that the information provided will be used to assess my suitability for supported accommodation with Proffer Solution Ltd. I consent to relevant checks and information sharing with support services and agencies involved in my care.

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