Needs Assessment and Application for Supported Accommodation

YMCA Use Only

Date

Time

The YMCA provides supported accommodation for young single people between 16 and 30 years old. If you would like to apply, please fill this form out clearly. If you find this form difficult to understand, please speak to a member of staff.

If you would like to find out more about our accommodation before sending your application, please click here.

Name *

First

Last

Date of birth//

Gender identity

Sexual orientation

Telephone number

Email

What is the best way for us to contact you about your application? *

National insurance number

Name of person completing form (if different from above)

Current address *

Previous address info, including landlord and reason for leaving *

Other previous address info, including landlord and reason for leaving *

Where else have you lived over the past six years? *

Have you lived at YMCA Doncaster before?

Yes
No

Please provide details of any professionals who you’ve had support from now or in the past. We will use the details below to obtain references to support your application.

By providing the details of the worker, you are giving YMCA Doncaster consent to discuss your application with them.

Probation Officer *

Yes
No

Youth Offending Officer *

Yes
No

Social Worker *

Yes
No

Keyworker / Case Worker *

Yes
No

Support Worker *

Yes
No

Teacher / Tutor *

Yes
No

Advocacy Worker *

Yes
No

CPN / Mental Health Worker *

Yes
No

Counsellor *

Yes
No

Other worker *

Yes
No

What is your current income - for example, from benefits or employment?

How much do you receive?

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

0-5 Units
5-15 Units
15-25 Units
25+ Units

Are you currently receiving support with reduced drinking? *

Yes
No

Do you have any physical health problems or illnesses or any mobility requirements? *

Yes
No

Do you have needs that require additional support, including learning difficulties? *

Yes
No

Do you have any known allergies? *

Yes
No

Are you pregnant? *

Yes
No

Do you consider yourself to have a disability? *

Yes
No

Are you registered disabled? *

Yes
No

Do you require accommodation for use by wheelchair? *

Yes
No

Do you suffer from any mental health problems? *

Yes
No

Do you currently have a Probation / Youth Offending order? *

Yes
No

Have you been convicted of a criminal offence or received a caution or ASBO? *

Yes
No

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

Yes
No

Have you ever been convicted of arson? *

Yes
No

Is there anything else you would like to add to your application?

Declaration

All of the information provided on this form is true and complete. I will tell YMCA Doncaster straight away if there are any changes. I understand that any false information I give can affect my application.

I understand that the information given as part of this application, and information provided or disclosed by myself or others later, will be stored by YMCA Doncaster whether or not my application is accepted.

If I am offered a supported accommodation place, I understand that information about my support needs and progress, rent, finances and matters related to the accommodation will be stored by YMCA Doncaster and that data relating to my support provision may be provided to YMCA Doncaster's funders.

I understand that this is an application to take part in a programme of structured support, and I am willing to take part fully in that support.

Please write your full name to confirm you have read and agree to the above declaration *

Our first step is to find references for you. We will then invite you for an interview and discussion about the support service. After your interview, we will contact you to let you know whether you’ve been placed on our waiting list.

You can contact us during office hours to check how your application is coming along. Please call 01302 342148.

If you feel that we have not handled your application fairly and properly, please write to Appeals, YMCA Doncaster, Wood Street, Doncaster, DN1 3LH

Consent for References and Move-On Information

In order to assess your need for Supported Accommodation, and for us to monitor your progress once you move on from the YMCA, we will need to request information from professionals who know you well, your past, present and future landlord(s) and anyone else who may be able to advise on your support needs. We therefore need you to complete the boxes and the declaration below.

Client name

Date of birth//

Current Address

I, the above named person, have applied for Supported Accommodation at YMCA Doncaster and have been asked to supply information about possible referees and other professionals who know me through their service. I therefore give my consent for relevant information to be released to YMCA Doncaster, at their request, to enable them to complete a full background check.

I also understand that, for a period of up to one year after leaving YMCA Doncaster (which will be no later than three and a half years after the date of below), YMCA Doncaster may request information on my new accommodation and support provision, including personal information relevant to the monitoring of their services.

I therefore request that, should YMCA Doncaster request this information from future landlord(s), support provider(s) or other professional(s), that this is provided to them in order to evidence the service. I appreciate your co-operation and would like to thank you in advance.

Date *//

Please write your full name to confirm you have read and agree to the above declaration *