Form Test - Langley : Langley

Applicants Details

Please complete this form as fully as possible

Preferred Project

(see Referrals Pack) or floating support service

Title

Forename/s

Surname

Marital status

Current Accommodation

Please tick if any of the following apply to your current accommodation.

Prison (state prison number)

Hospital (please name if not previously provided)

In a local care authority (please name)

A registered care home (please name if not previously provided)

Rented – local authority/social landlord (name area)

Rented – private sector (name area)

Other

Give details

Telephone

Mobile

National Insurance Number

Date of Birth

DD slash MM slash YYYY

Gender

Male

Female

Transgender

Have you served in His Majesty’s forces?

Yes

Have you served in Her Majesty’s forces?

Army

Navy

Airforce

Previous Accommodation & Rent Arrears

Address 1 Details

ADDRESS HERE

Owning Property

Do you or your partner currently own a property?

Yes

Have you or your partner owned a property in the last 5 years?

Yes

Name of the owner

Address of the property

Postcode

How much is/was the property worth?

Rent Arrears

Current rent arrears

Previous rent arrears

Any other debt or financial problems

Availability for work and how this affects benefits

Past difficulties in claiming Housing Benefit

Current Legal Status

Please tick all that apply:

MAPPA L1*

MAPPA L2*

MAPPA L3*

CPPC (Critical Public Protection Case)

Bail

ACR (Automatic Conditional Release)

DCR (Discretionary Conditional Release)

HDC (Home Detention Curfew)

YOI (Youth Offending Institute)

Life Licence

IPP (Imprisonment for Public Protection)

SHPO (Sexual Harm Prevention Order)

SOR (Sex Offender Register)

* Multi Agency Public Protection Arrangements

Date information

Automatic Release Date

Parole Eligibility Date

Non Parole Date

Extended Licence Expiry

Licence Expiry Date

Sentence Expiry Date

Life Licence

Home Detention Curfew

Referral Date

Date Place Required

Details of person making the referral

Full Name

Address

Tel

Details of Offender Manager or Social Worker

Full Name

Address

Tel

Other e.g. Offender Supervisor / Solicitor / Chaplain / Family / Friend (circle as appropriate)

Full Name

Address

Tel

Current Legal Status (continued)

Documents to be forwarded:

Previous convictions (up-to-date)*

Pre-sentence Report*

OASys / Relevant Risk Assessment document*

MAPPA Minutes (previous two sets)

Psychiatric / Psychological Report

Parole Assessment Report

Community Care Assessment

Licence

*Mandatory – the requirement of this information is supported by Probation Circular April 2013 and Langley’s Service Level Agreement with the Ministry of Justice. Failure to provide this information will result in a delay to your application.

N.B. For some applicants this information may not be available. This does not mean that these applications will not go forward. They will need to be approved by the Referral Team.

Further Client Details

History of suicidal / self-harm behaviour (please give details)

Substance abuse history:

Alcohol

Amphetamines

Benzodiazepines

Crack

Cannabis

Cocaine

Ecstacy

Hallucinogens

Heroin

Methadone

Misused prescribed drugs

New psychoactive substances

Steroids

Solvents (inc. gases & glues)

Other (please give details)

State main drug if more than one substance used

Details of physical or medical disability, including current medication and dosage

Has the individual ever been sectioned under the Mental Health Act?

Yes

Details of psychiatric history, including any medication and dosage

Cultural Requirements

Preferred language (if NOT English) - Written)

Preferred language (if NOT English) - Spoken

Is an interpreter required? (please give details)

Special dietary requirements

Equal Opportunities

All Housing Associations are required to collect data about an applicant’s age, disabilities, gender or gender identity, ethnicity, religion or belief and sexual orientation. The information will be used solely for monitoring purposes to ensure that our policies and procedures are effective. The Trust is committed to the principles of fairness, consistency, meritocracy and equality of opportunity. No applicants will be discriminated against regardless of their age, colour, disability, ethnicity, gender or gender identity, race, religion or belief and/or sexual orientation. No applicant will be discriminated against if they do not wish to complete this part of the form, which is optional.

Please tick any statement that is appropriate to you:

Dyslexic

Blind / partially sighted

Deaf / hearing impaired

Require personal care support

Wheelchair user

Mobility difficulties

Registered disabled

Mental health difficulties

Learning disability

Unseen disability e.g. diabetes, sickle cell

Illness / disability not listed (please give details)

Please tick the box that best describes your race and ethnicity

British

Irish

White & Black Caribbean

White & Black African

White & Asian

Indian

Pakistani

Bangladeshi

African

Caribbean

Chinese

Not stated

Please tick what you consider your sexual orientation to be

Opposite sex

Same sex

Either sex

Declined to answer

Please tick if you have been gender reassigned

Yes

Declined to answer

My religion / belief is

Consent for Data Processing

This permission can be given on a separate sheet and attached.

I give my permission for Langley House Trust to hold and process information about me as well as to pass information to appropriate third parties in order to:

Decide whether to offer me a place
Assess me and manage my progress while I am a resident (if admitted)
Help me plan for a satisfactory move on

How you heard about our services - Person being referred / self-referral

Recommended by resettlement officer / probation officer / chaplain

Saw listing in a directory

Heard about Langley at a conference

Saw listing in a directory

Heard about Langley at a conference

Via the Langley website

How you heard about our services - Professional / person making the referral

Recommended by resettlement officer / probation officer / chaplain

Saw listing in a directory

Heard about Langley at a conference

Saw listing in a directory

Heard about Langley at a conference

Via the Langley website

Any additional information (e.g. your expectations of this placement / length of stay / move-on plans)

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