Application form - Islington Council

Applicant’s Name:
Database number:
Application form
Islington Families
Floating Support
▪ Please complete this form in black ink or type
▪ Complete all sections fully to ensure we have as much information as
possible for our assessment
CONTACT LOG
Name Date Action
Interpreter Reference No:
Female Interpreter
needed ?
Date Booked:
Y
N

This section is for EPIC use only
PERSONAL DETAILS
Name of Lead
Service User
Address
Tel Nos:
Home:
Work Mob :
Date of birth:
National Insurance number
Housing Benefit Reference Number
Tenancy Reference Number
Sex:
COMMUNICATION REQUIREMENTS
Has the applicant any special communication requirements, which would help us, deal
with the application?
If yes, please give details:
Interpreter Required
Female interpreter required
Yes No
Yes No
□ Yes (give details)………… ……………………………………………………………..
How easily can the applicant read English?
Easily
Only large print
Cannot read English
If not English, what is the applicant's
main written language?
Braille
Turkish
Somali
Albanian
Bengali
None
Other (please specify)
How easily can the applicant understand
English?
Easily
Simple English only
Cannot speak English
If not English, what is the applicant's
main spoken language?
Sign Language
Turkish
Somali
Albanian
Bengali
Other (please specify)
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REFERRAL DETAILS
Self
Friend/family
member or
advocate
Yes
Yes
No
IF REFERRED BY A VOLUNTARY OR STATUTORY AGENCY PLEASE
PROVIDE INFORMATION BELOW
Organisation Name
Name of person making the
referral
Telephone No.
Address
Date
Allocated Social Worker? Yes □
Name if different from referrer:
No □
Applicant aware of Referral?
IF SOCIAL SERVICES REFERRAL IS THERE ANY:
• Childcare issues or Child behavioural problems?
• Parenting support needed?
PRESENT ACCOMMODATION please tick and add details where relevant
Council Circle 33 Housing Association Other
Lodgings Foster parents Hostel
B&B Hospital Private tenant
With friends With relatives Owner / part owner
IS ACCOMMODATION PERMANENT OR TEMPORARY please tick relevant box
PERMANENT
TEMPORARY
If living in the borough of Islington, how long has this been for?
(in years and months)
If less than six months, where did you live before and for how long?
(which housing authority)
If not living in Islington, how long have you lived in this borough?
(in years and months)
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HOUSEHOLD Details: if there are other members of your household, please give
the following details :
Surname First name D o B Sex:
(M / F)
Relationship to
applicant 1
1 State actual relationship to applicant: e.g. partner, son, daughter etc
SUPPORT
Preferred Support Co-ordinator Gender Male Female
RACs to complete
Outline of support needs
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BENEFITS
Are you receiving welfare benefits at the moment? Yes
No
Income Support JSA
DLA Incapacity
Housing Benefit
Tax Credits
Other services involved, e.g. Statutory Mental Health services, voluntary agencies,
day centres, etc:
Name Agency Nature of service Contact details
RISK MANAGEMENT
Is there anything that might put our worker at risk when they visit? E.g. Pets, risk of
violence/verbal abuse from someone at property or someone visiting, domestic
violence, nuisance neighbours, TB, large estate, cockroaches, bed bugs etc
Give detail of risk and if none known write ‘none known’
Does anyone living in your home have any skin conditions that may have been
caused by your living conditions? No Yes
Support Needs Prompts – Completed by RAC
Refugee
Language / communication
Housing / Tenancy issues
Learning difficulty
Relationship breakdown
Child Protection (on register)
Child Support issues
Employment / Education / Training
Bereavement
Domestic violence
Substance dependency
Physical Health
Mental Health
Homeless
Immigration
Income & Benefit
Temp – Perm accom
Other – please specify
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EOP’s DIVERSITY MONITORING
We monitor a range of information about our customers to help us to provide a suitable service and
ensure people are not discriminated against because of their race, language, disability, faith or sexual
orientation. Please provide us with the following information to help us do this.
What is the first language used by the
applicant?
What is the ethnicity of the applicant? (use code
from list at back of this form)
Does the applicant belong to one or more of these groups? Tick all boxes that apply.
Gypsy or Traveller
Refugee
Migrant Worker
Does the applicant consider himself/herself as
having a disability?
None of these
Yes
No
What type of disability does the applicant have? Tick all boxes that apply.
Blind
Partially sighted
Profoundly deaf
Speech impairment
Limited mobility
Wheelchair use (full)
Mental health
Partial hearing
Learning difficulties
Physical co-ordination difficulties
Wheelchair use (partial)
Other (please note below)
Circle Anglia has a policy of equal access regardless of language needs or disability. Do you require
any particular communication arrangements?
Written translation into first
Spoken interpretation into first language
language
Large print English
Audio CD
Braille
Large print first language
Audio cassette
Pictorial
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Type Talk
British Sign Language interpreter
Makaton
Minicom
Text
Do you need any other particular arrangements
or adjustments to the service provided by Circle
Anglia?
(If yes, please give details)
What is the religion of the applicant?
None
Buddhist
Hindu
Christian
(including Church of England,
Catholic,
Protestant and all other Christian
denominations)
Jewish
Muslim
Sikh
Prefer not to say
Any other religion (please write below)
What is the sexual orientation of the applicant?
Bisexual
Gay man
Gay woman / lesbian
Heterosexual / straight
Other
Prefer not to say
How would you describe your ethnic origin? [Please choose one code only]
Code Description
White
1 British
2 Irish
3 Other
Mixed
4 White & Black Caribbean
5 White & Black African
6 White & Asian
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7 Other
Asian / Asian British
8 Indian
9 Pakistani
10 Bangladeshi
11 Other
Black / Black British
12 Caribbean
13 African
14 Other
15 Chinese
16 Other
Chinese/other ethnic group
17 Refused
Circle Anglia will store this data to ensure that we are providing services of equal
quality to all customers. We may pass this data in anonymous statistical form to the
Housing Corporation, or other public bodies, for them to perform their duties.
I declare that the information on this form is a true statement and I consent to it being
used for the purposes described.
……………………………………………….. Applicant signature
EPIC to complete for monitoring purposes at the end of the process for
each applicant
Applicant accepted for service Yes □ No □
If applicant not accepted state reason for rejection
………………………………………………………………………………………………..
DECLARATION – Not to be completed by an agency making a referral
To be read and competed by applicant
Please sign to show that the information given on this form is accurate and that you
agree with the confidentiality statement below
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CONFIDENTIALITY STATEMENT
We understand that from time to time EPIC Trust will share certain information about
ourselves with your local borough and other agencies on a need to know basis. This
will only be done when it affects the support service that we are receiving. EPIC Trust
will try to tell me what they are sharing and to who, before they do so.
The exception to this agreement is in cases where EPIC Trust has a statutory duty to
pass information on, for instance if a crime is going to be committed or there are
serious concerns about a person’s welfare e.g. child protection or self harm etc.
Signature of applicant/s
Date
Please return completed application form to:
Islington Families
EPIC Trust
84 Mayton Street
London N7 6QT.
Tel. 0845 600 1055
Fax: 0207 700 3674/ 0845 234 5696
Email: Islington.families@circleanglia.org
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