Application form - Islington Council

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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) Page 2 of 9
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) Page 3 of 9
Page 1: Applicant’s Name: Database number
Page 5 and 6: BENEFITS Are you receiving welfare
Page 7 and 8: Type Talk British Sign Language int
Page 9: CONFIDENTIALITY STATEMENT We unders

Application form - Islington Council

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