Contact Us – Goddess Living Supported Housing Limited

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Alternatively, you can fill out the form below with your details and a brief message and one of our team members will get back to you promptly.

Office address

C/O Bluewater Tax, Quadrant Court, 49 Calthorpe Road, Birmingham, B15 1TH

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Declaration

I agree that the information contained in this referral / initial assessment form is true and accurate and I consent to it being used as part of the assessment process.
By Signing below, I agree that all information provided is true and accurate. I also understand that Goddess Living Supported Housing has the right to close my housing application should I provide any information which is incorrect or false. Should it be discovered that I have secured a tenancy with false information, I may be liable to be served with a Section 8 notice.

I agree to the above declaration

I do not agree to the above declaration

Information Sharing

I understand that Goddess Living Supported Housing may carry out additional checks on the information I have provided by contacting other agencies (for example : mental health services/probation officer/police services) . Please state if you give permission for information to be shared with relevant agencies to inform accurate assessment of housing needs and risk.

I consent to information sharing

I do not consent to information sharing

Referral Agency

Name of person making referral

Referral Agency contact number

Reason for referral

Areas required for accommodation

Date of Referral

Applicant Details

Applicant Name Including title

Date of Birth

Place of Birth

National insurance number

Gender

Contact details

Current Address

Ethnic origin of applicant

Does the applicant follow a religion?

Please provide details :

Financial information

What benefits do you currently receive?

How often are your benefits paid?

Total amount received

Do you receive PiP?

If yes, what rate of PiP do you receive?

Offending History

Please note – Declaration of criminal offence(s) does not necessarily mean that you will be excluded from applying for accommodation with Goddess Living Supported Housing .

Have you ever been convicted of a criminal offence? (including spent offences) Or do you have any pending court appearances or subject to bail conditions?

Yes No

Nature of offence

Date

Probation officer name

Probation officer contact number

Probation officer email

Probation office

Housing History

3 years housing history required

Address

Dates

Tenure

Landlord Details

Reason for leaving

Medical information

Is the applicant allocated a Social Worker?

Yes No

Is the applicant registered with a GP?
If yes provide details:

Yes No

Has the applicant ever been sectioned/detained under the mental health act or subject to a community treatment order?

Yes No

Mental health history (including any diagnosis)

Does the applicant receive any support regarding their mental health? CPN, CMHT

Yes No

Does the applicant have any learning difficulties?

Yes No

Physical health history

Ground floor room required?

Yes No

Applicants present medication or treatment :

Details of Care Plan Approach:

Substance misuse

Does the applicant currently use drugs?
Please include details on regularity of use, administration ect.

Yes No

Does the applicant have a drugs worker?

Yes No

If no, is the applicant open to engaging with drug use support?

Yes No Not Required

Does the applicant currently drink Alcohol? Please include details of regularity

Yes No

How often?

Does the applicant receive any support around alcohol use?

Yes No Not Required

Does the applicant receive any support around alcohol use?

If no, is the applicant open to support to address alcohol use?

Yes No Not Required

Support Needs

Reasons for requiring supported accommodation

At risk of becoming homeless/ evicted within the next 28 days

Ability to manage mental health

On going issues with drug misuse

On going issues with alcohol misuse

Ability to engage with Mental health services

On going issues with alcohol misuse

Medication prompts

Attending appointments

Appointment reminders

Accessing drug and alcohol services

Medication ordering/collection

Access to GP/ Health services

Ability to manage physical health

Improved quality of life

Building healthy support networks

Ability to manage personal hygiene

Developing Independent living skills

Risk of domestic abuse (victim)

Risk of Domestic abuse (perpetrator)

Reduce social isolation

Involvement in community activities

Obtaining training / education opportunities

Obtaining volunteering opportunities

Obtaining employment

Financial support required – Budgeting

Risk of offending

Risk of harm for others

Risk of self harm / suicide attempts

Reduced feelings of isolation

Ability to keep home safe and secure

Developing problem solving skills

Developing interpersonal skills

Increased confidence

Other identified support needs

Risk Assessment

Please provide information below (or send a current risk assessment)
Risk Guidance : Low risk – No evidence of behaviours related to risk. Medium Risk – Evidence of behaviours linked to risk but is engaging with support to address this. High Risk – Regular engagement with behaviours linked to risk and is not engaging with support to address this.

Does the applicant have history of the following risks?

Is this risk assessment a self assessment ?

Is this risk assessment a professional assessment?

Violent or aggressive behaviour

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Self-Harm / Suicide attempts

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Mental health

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Drug/ Alcohol misuse

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Medication: Non-compliance with prescribed medication

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Child protection issues? Schedule one offences?

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Sexual offending? Please include details of who the risk is posed to (e.g Adult male/female/children)

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Any other criminal offences/ Convictions? Include risk to Staff/ Tenants/ General public

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Risk of self neglect / Self Care

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Anti Social behaviour

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Damage to property

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Arson/ Firearms offences

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Rent arrears / Managing finances

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

harm

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Should any additional precautions be taken into account when interviewing the applicant?

Indicate Risk level L

Indicate Risk level M

Indicate Risk level H

Have additional checks been completed?

Yes No

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Mail address

Office address

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