Views External

Identity

Title

Forename

Surname

Date Of Birth

Gender identity

National Insurance Number

Contact

Telephone

Address

Address Line 2

Town

Post Code

Landlord Details (Name, address telephone number)

Date moved in to current accommodation (approx)

Employment, Education and Training

Are you a veteran or member of the armed forces?

Communication and Physical Needs

First Language Spoken

Other Languages Spoken

Do you require an Interpreter?

Language of Interpreter required.

Do you consider yourself to have a disability?

Are you registered as disabled?

Do you require wheelchair access?

Do you have any needs that require additional support?

If yes, please provide details

Are you pregnant?

If yes, what is your due date?

Do you have any allergies?

If yes, please provide details

Name of person completing the form, if different from above

Previous Contact

Have you lived at YMCA Doncaster before?

If yes, please provide approximate dates

Please provide your reason for leaving YMCA Doncaster

Please provide details of any activies attended at YMCA Doncaster

Please Provide Details of The Last Three Places You Have Lived

Address

Dates from and to

Type of accommodation

Main reason for leaving

Address 2

Date from and to

Type of accommodation

Main reason for leaving

Address 3

Dates from and to

Type of accommodation

Main reason for leaving

Where else have you lived over the past six years?

Mental Health

Do you suffer from any mental health problems?

If yes, please provide details

Alcohol and Substance Misuse

Have you ever used Cannabis?

Have you ever used Heroin?

Have you ever used Cocaine (including Crack Cocaine)?

Have you ever used Methadone?

Have you ever used Blockers / Detox?

Have you ever used legal highs or spice?

How many units of alcohol do you drink each week (on average)?

Offending

Do you currently have a Probation / Youth Offending order?

If yes, please provide details

Have you been convicted of a criminal offence?

If yes, please provide details

Have you received a Caution, Civil Injunction, Community Protection Order, or ASBO?

If yes, please provide details

Have you ever been convicted of a sex offence or an offence of a sexual nature?

If yes, please provide details

Have you ever been convicted of arson?

If yes, please provide details

Finances

What is your current income (from benefits/employment etc)?

How much do you receive?