Initial Housing Assessment Form
April 2011 onwards
Please check all questions - you cannot change it once you press submit.
All questions with a star (*) are required fields
*Name of your organisation
*Date the household came to you
*The agency who referred the household to you
Are you a care leaver?
Yes
No
*Gender
Male
Female
Number of dependent children
*Client Code
i.e. JB010190M
*Is a member of the household registered disabled?
Don't Know
*Is a member of the household pregnant?
*Age Group
20 - 24
46 - 59
15 or under
25 - 35
60+
16 - 17
36 - 45
18 - 19
*Household Type
Couple
Separated Parent
Single
Couple with children
Single Parent
Guardian
*Ethnicity
White - British
Black - Caribbean
Asian - other
White - Irish
Black - British
White & Black African
White - other
Black - African
White & Black Caribbean
Gypsy/ Irish Traveller
Black - other
White & Asian
Show People
Asian - British
Mixed - other
Chinese
Asian - Bangladeshi
No response
Chinese - British
Asian - Indian
Chinese - other
Asian - Pakistani
*Status Today
No accommodation of own
Threatened with homelessness
Accommodation acceptable
Unsuitable accommodation
Need to leave own home
Homeless
NTQ/eviction
*Last Settled Place of Residence
Cheltenham
Forest of Dean
Stroud
Other South West
EU
Cotswold
Gloucester
Tewkesbury
Other UK
Outside EU
*Current Circumstance (type of housing they live in)
Parents
Armed Forces
Hospital
Rough Sleeping
Prison
B & B
Housing Association
Squatting
Private Rented
Car
Lodger
Supported Housing
Mobile Home/Caravan
Refuge
Council tenant
Supported Lodgings
Rehab
Friends
Nightstop
Tied accommodation
Relatives
Hostel
Owner Occupier
*Household Income - please state all sources of income for the household
Employment Support Allowance
State Pension
Attendence Allowance
Private Pension
Care Leavers Allowance
Housing Benefit
Incapacity Benefit
Carers Allowance
Pension Credit
Income Support
Student Loan
Child Benefit
Training Allowance
Child Tax Credits
Job Seekers Allowance
Council Tax Benefit
NONE
Wages/ Earnings
NONE but applying for benefits
Disability Living Allowance
Working Tax Credits
Educational Maintenance Allowance
Not known
Does anyone in the household have any of the following? (tick all that apply to your household)
autism/aspergers
learning disability
physical disability
health problem
mental health issue
sensory disability
*Primary reason for the household seeking advice/ assistance
Scroll down to find the most appropriate answer
*If the household REQUESTS support, please tick what they require
Alcohol
Education
Mental health
Advocacy
Emotional difficulties
Benefits Advice
Family mediation
Tenancy support
Debt/money problems
Fleeing violence
Training/ Job
Disability
Frail elderly
Translation Services
Drugs
Literacy/numeracy
DO NOT INCLUDE YOUR ORGANISATION
*Is this household receiving support from any of the following agencies?
2gether
Family Mediation service
Primary Care Trust
ASTRA
Independence Trust
Rethink
Autism services (GCC)
GDVSAP
Shelter
Bromford
GEAR
SHOP
CAB
Gloucestershire Homeseeker
SPA
CARP
GRIP
Soulutions
CBC Housing Options Team
Guideposts
SP Deposit Loan Scheme
CCP
G3
Stonham
CHAC
Job Centre
Vaughan Centre
Children & YP Directorate
Knightstone
YMCA
Comm & Adult Care Directorate
National Youth Advocacy Service
Youth service
Connexions
Nelson Trust
Youth Housing Advice Service
Crisis Loan
Victim Support
ECHG
YP Substance Misuse Service
Emmaus
Other Glos District Council
*Have you referred the household to any of the following agencies?