The Bridge Trust - | Application Form

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Application Form

Before completing the following application form please read the following questions. If you cannot tick YES to ALL of the following questions then you should not apply as your application will be unsuccessful. This is because you will not fulfil our admissions criteria.

Are you 18 years of age or older? *

Are you homeless, under threat of homelessness or in housing need? *

Are you single? *

Have you an identifiable support need that means that you could not achieve independence without the support we provide? *

Do you have the ambition and capability to live independently? *

Are you willing to accept and participate in a programme of support to that end? *

Are you willing to live in shared accommodation with people with similar support needs? *

Are you realistically able to achieve independence within two years? *

Please note that The Bridge Trust provides hostel accommodation and supported accommodation. We are not therefore simply a landlord.

Residents are expected to work with staff in a programme of support towards the goal of independence. If you do not wish to do this then you should not apply for accommodation with The Bridge Trust. Please note that residents who cannot work with staff towards independence are not allowed to remain in Bridge Trust accommodation.

However if you ticked Yes to the above list of questions and genuinely want to work alongside our staff to achieve independence then we look forward to receiving your application.

You do not fulfil our admissions criteria

Sorry but it looks like you're not eligible for our support at this time.

Supported Accommodation Application Form

Strictly Confidential

This form is the first stage of the application/referral process; the details requested assist The Bridge Trust to form a decision whether the service can meet an individual’s needs. The form may be completed by the applicant (self-referral) or referrer. Bridge Trust support staff may also complete this form with you during an interview. If you experience difficulty completing the form, please telephone The Bridge Trust on 01732 368363. It is important that all information is complete, accurate and true; failure to disclose details at this stage may lead to the service offered being withdrawn. All details will be treated confidentially.

In order to comply with the requirements of the Data Protection Act 1998, The Bridge Trust requires your consent for its use and disclosure of information relating to you. Your information will only be processed for lawful purposes.

Applicant Details

Full Name *

Preferred Name *

Previous/Other Names

Date of Birth *

Gender *
Male
Female
Transgender
Do not wish to answer

N.I. No *

Contact Address

House Name / Number

Street

Town / City

County

Postcode

Contact No

Email Address *

What is your Marital Status? *
Single
Married
Separated
Divorced
Widowed
Civil Partnership

Are you responsible for any children or other dependents? *
Yes
No

Please give details of your responsibilities below

Accommodation

All our bedrooms are designed to be shared, although we try to avoid this if we can. If the only room available was a shared bedroom, would you rather *
Share a room
Wait until a single room becomes available

Please give reasons why you feel you need a single room *

Do you know anyone who has lived or is now living with The Bridge Trust? *
Yes
No

Please give their name and describe how you know them. *

Have you applied to The Bridge Trust before? *
Yes
No

When did you apply? *

Health

Are you registered with a local G.P. (doctor)? *
Yes
No

Doctor's Name *

Address 1 *

Street *

Town / City *

County *

Postcode *

Income

Please tick what type of income you receive or are waiting to hear if you will receive: *
Employed – Full Time
Employed – Part Time
Self-employed
Universal Credit
Job Seekers Allowance
Income Support
Incapacity Benefit/Employment Support Allowance
Training Allowance
D.L.A. – Care Component
D.L.A. – Mobility Component
Statutory Sick Pay
Widow’s Pension
Attendance Allowance – high rate
Attendance Allowance – low rate
State Pension
Occupational Pension(s)
Disability Working Tax Credit
Working Tax Credit
Other

You selected Other, please give details *

Do you have any savings? *
Yes
No

What is your weekly income? *

Are you able to provide proof of your income? *
Yes
No

Are you in receipt of Housing Benefit? *
Yes
No

Are you able to provide proof of your identity? *
Yes
No

Please tick what proof of identity you have *
Birth Certificate
Passport
Driving Licence
Medical Card
Other

You selected Other, please give details *

Are you currently employed? *
Yes
No

As you answered No, are you willing to take up employment, with appropriate support, in the next 24 months? *
Yes
No

As you answered No to the above question, please explain why below: *

Housing History

Are you currently, or about to become homeless? *
Yes
No

Where are you currently living? *
Housing Association Tenant
Registered Care/Nursing Home
Local authority Tenant
Self-contained supported housing
Private Tenant
Hospital
Owner Occupier
Temporary Accommodation
Living with family
Living with friends
Prison
Approved probation/bail hostel
Homeless – Rough sleeping
Homeless – Sofa surfing
Children’s home/foster care
Other

You selected Other, please give details *

Please give details of your present situation: What are the reasons for you becoming homeless? Have you lived in other hostel accommodation previously? If you are currently in a hostel please explain why you were homeless prior to your admission? *

Do you have any arrears owing to any previous landlord? *
Yes
No

Please state the address of the property, how much and to whom *

What is your previous housing history; have you experienced any difficulties in other accommodation? We may require addresses for the last five years to enable us to refer you to other providers.

Address 1

Date From

Date To

House Name / Number

Street

Town / City

County

Postcode

Type of accommodation & tenure (tenant, owner, lodging, etc)

Difficulties encountered

Reason for leaving

Address 2

Date From

Date To

House Name / Number

Street

Town / City

County

Postcode

Type of accommodation & tenure (tenant, owner, lodging, etc)

Difficulties encountered

Reason for leaving

Address 3

Date From

Date To

House Name / Number

Street

Town / City

County

Postcode

Type of accommodation & tenure (tenant, owner, lodging, etc)

Difficulties encountered

Reason for leaving

Address 4

Date From

Date To

House Name / Number

Street

Town / City

County

Postcode

Type of accommodation & tenure (tenant, owner, lodging, etc)

Difficulties encountered

Reason for leaving

Address 5

Date From

Date To

House Name / Number

Street

Town / City

County

Postcode

Type of accommodation & tenure (tenant, owner, lodging, etc)

Difficulties encountered

Reason for leaving

Address 6

Date From

Date To

House Name / Number

Street

Town / City

County

Postcode

Type of accommodation & tenure (tenant, owner, lodging, etc)

Difficulties encountered

Reason for leaving

Alcohol & Drug Dependency/Use

Any dependency issues will not automatically exclude people from being offered support; but we do require you to tell us about any issues with alcohol or drug use.

Have you ever experienced dependant or excessive alcohol use? *
Yes
No

Please give details; including whether this remains an issue for you now. *

Have you ever used any illegal drugs or misused substances? *
Yes
No

Which substances have you used; please tick all that apply. *
Acid
Aerosols/Gases
Amphetamines
Amyl/Butyl Nitrate
Cannabis
CB
Cocaine
Crack Cocaine
Crystal Meth
Ecstasy
Glue
GHB
Heroin
Ketamine
Khat
LSD
Magic Mushrooms
Methadone
Opium
PMA
Speed
Steroids
Tranquilisers
Other

Please give details of your usage; how long have you been using and whether you are still using now. *

Do you have anyone supporting you with this? *
Yes
No

Please provide their name and contact details if other than referrer. *

Criminal Convictions

The Bridge Trust reserves the right to refuse accommodation to people with a history of sexual offences, those with a recent history of violence or aggression or those with a history of recent or prolific theft offences. With these exceptions The Bridge Trust does not exclude people with a history of criminal activity; but we need details of any convictions you may have. Failure to disclose details at this stage may lead to the service offered being withdrawn.

Do you have any convictions including cautions to declare? *
Yes
No

What are the convictions associated with; please tick all that apply. *
Anti-social Behaviour
Arson
Assault
Battery
Burglary
Car Theft (TWOC)
Child Abuse
Criminal Damage
Drug - Possession/Supply
Kidnap
Rape/Sexual Assault
Robbery
Theft
Weapon – Possession/Supply/Use of
Other

You selected Other, please give details *

Please give details below; including any sentences served and any outstanding cases pending against you.

Do you have a Probation Officer or anyone else supporting you with this? *
Yes
No

Please provide their name and contact details if other than referrer *

Are you currently subject to, or have you ever been subject to:

- an ASBO (Anti Social Behaviour Order)? *
Yes
No

Please give details *

- a CBO (Criminal Behaviour Order)? *
Yes
No

Please give details *

- a Civil Injunction? *
Yes
No

Please give details *

Do you have any court cases pending? *
Yes
No

Please give details of your pending court cases *

Are you on bail or on licence? *
Yes
No

Please give details *

Have you ever been assessed as a higher risk under

- Care Programme Approach *
Yes
No

- Multi Agency Protection Arrangements (MAPPA) *
Yes
No

- Multi Agency Risk Assessment Conference (MARAC) *
Yes
No

Are you on the Violent and Sex Offender Register (ViSOR)? *
Yes
No

You selected Yes to one/some of the above, please give further details. *

Mental Health

Do you have any concerns regarding your mental health? *
Yes
No

How would you describe this? *
Behavioural Difficulties
Psychological Difficulties
Psychiatric Illness
Other

You selected Other, please give details *

Do you have a medical diagnosis of the above? *
Yes
No

Please define *

Have you experienced any hospital admissions in relation to the above? *
Yes
No

Please give details *

Do you have anyone supporting you with this? *
Yes
No

Please provide their name and contact details if other than referrer *

Are you currently under Care Programme Approach? *
Yes
No

At what level? *
Standard
Enhanced

Please give the name and contact details of your care-co-ordinator *

Physical Health

Do you have any concerns regarding your physical health? *
Yes
No

Do you have any physical disabilities? *
Yes
No

Do you have any sensory disabilities? *
Yes
No

Are you registered disabled? *
Yes
No

Do you have any physical health conditions? *
Yes
No

Please give details regarding any physical health conditions. *

Do you have anyone supporting you with this? *
Yes
No

Please provide their name and contact details if other than referrer *

Have you been in hospital in the last 5 years? *
Yes
No

Please give details *

Prescribed Medication

Are you prescribed any medication? *
Yes
No

Please give details *

Contributory Factors

The following lists other factors that may have contributed to you becoming homeless or being in need of support to acquire and/or manage your future accommodation successfully; please tick all that you feel may apply.

Contributory Factors *
Family/Relationship Breakdown
Harassment
Threat of Eviction
Rough Sleeping
Leaving Care
Asylum Seeker
End of Tenancy
Abuse
Domestic Violence
Gambling
Rent Arrears
Repossession
Financial Difficulties
Overcrowding
Loss of Job
Complex Needs
Pregnancy
Alcohol Issues
Drug Dependency
Other

Please give brief details of any you have ticked *

Housing Future

What are you hoping this service will assist you to achieve? *

Support Needs

Please use this area to indicate the areas of support that you require. It is this information that will form the basis of the support plan if your application is successful.

We are specifically set up to provide support linked to accommodation – regrettably applicants who do not have any support needs cannot be accepted.

Please tick below the areas that you need support with. To be considered for assessment you must identify your support needs: *
Budgeting welfare benefits- Ability to manage money and access benefits
Training and employment - wanting to access
Education/literacy - wanting to access
Social Activity - Hobbies, recreational activities- help to access
Family - Assistance to maintain links
Independent living skills - To learn to live independently eg cooking, shopping, cleaning
Health and Lifestyle - How you manage own health, alcohol/drug use
Personal safety/vulnerabilities - Ability to identify risk and maintain own safety
Emotional well being/mental health - State of mind and mental health condition
Physical limitations - Ability to manage on a day to day basis eg aids and adaptations
Culture and faith- Support to pursue personal beliefs
Future choices - Help with deciding future decisions and actions
Other needs - Any other support not already identified

You selected Other needs, please give details *

Do you have problems with reading and/or writing? *
Yes
No

Do you have any pets? *
Yes
No

Please give details *

Supporting Your Application

Is there anything else you would like to tell us regarding your circumstances or your application? *
Yes
No

Please give details *

Additional Information

If either the applicant or referrer would like to give any additional information please enter it below.

Additional Information

References

Please give the names & addresses of two people who have known you for at least two years and are not related to you – one of these can be the referring agent.

First Reference

Name

House Name / Number

Street

Town / City

County

Postcode

How long have you known this person?

How do you know this person?

Second Reference

Name

House Name / Number

Street

Town / City

County

Postcode

How long have you known this person?

How do you know this person?

Equal Opportunities Monitoring Form

Please complete this form and submit it with your application. The information on this form will only be used to monitor the effectiveness of our Equal Opportunities Policy and forms no
part of the accommodation application process. If you do not wish to complete any or all parts of this monitoring form it will not affect how we process your application in any way.

Upon receipt of your application this form will be detached from your application and stored separately. In compliance with the Data Protection Act, all information you give will be strictly
confidential.

Sex
Male
Female
Transgender
Transgender

Age
Under 18
18 – 25
26 – 50
51 – 64
65 and over

Ethnic Monitoring

Please make sure you read all the categories and place a cross in the box that applies to you.
White British
White Irish
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Other mixed background
Indian
Pakistani
Any other Asian background
Caribbean
African
Any other Black background
Chinese
Other ethnic group
Refused

Disability

Do you consider yourself to have a disability?
Yes
No

What category does it fall under?
Hearing, speech or visual impairment
Co-ordination, mobility or dexterity
Mental health
Learning difficulties
Other physical or mental disability

Please state nature of disability

Do you have any special access requirements?
Yes
No

Please specify your special access requirements

Sexuality
Heterosexual
Bisexual
Gay
Lesbian
Other

You selected Other, please give details

Religion
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
None
Other

You selected Other, please give details

Consent

Permission to share information with External Agencies and Individuals.

I understand that in order to undertake its responsibilities effectively, Staff at The Bridge Trust may need to share information it holds about me to External Agencies and Individuals. Fill in the consent fields below to indicate that you give permission for them to do that, with the following provisos:

1 - The process should be intended to be of benefit to me.
2 - All the information sought or divulged will be relevant to progressing this application.

Name *

Date *

I give permission for The Bridge Trust to share information required in the processing of this application. *

Application Form Author and Submit

The information I have given in this form is, to the best of my knowledge, true and accurate. I understand that giving false information at this stage may put any accommodation I am offered or obtain in jeopardy. *

Who filled in this form? *
Me
A Referral Agency Staff Member/Volunteer

Agency Name *

Name of Staff Member/Volunteer *

Address of Agency *

Contact Number *

Are you, the referring agent, willing to provide a character reference for the Applicant? *
Yes
No

Please explain why not *

Once you click "Submit Form", a confirmation message will appear. If you do not see this message then you have not completed the form correctly and you will be returned to the fist page that requires amendment.

Application Help

Before you begin the application process you will need at hand details of your income, past addresses, your doctor, agency etc. You can Register with the The Bridge Trust website, login and then you can save your progress at any time. The site will remember what you have filled in for 14 days. You can return, complete and submit the form at any time within those 14 days.

Required Questions

All questions marked with an * must be completed otherwise you won’t be able to submit the form.

For any questions marked with an * which are left blank, when you reach the end of the form it will return you to the page where the missing information is required and will keep doing so until all * fields on all pages are completed. If the form takes you back to a required field you have missed, once you have answered that question you will need to click [Next] through each page until you reach the end of the form again. This will keep happening until all required fields are completed.

Confidentiality of Information

The Bridge Trust is a registered “data controller” and any information you provide will be used only for lawful purposes in accordance with the UK Data Protection Act 1998 and the EU General Data Protection Regulations.

Application Form

You do not fulfil our admissions criteria

Supported Accommodation Application Form

Strictly Confidential

Applicant Details

Contact Address

Accommodation

Health

Income

Housing History

Address 1

Address 2

Address 3

Address 4

Address 5

Address 6

Alcohol & Drug Dependency/Use

Criminal Convictions

Mental Health

Physical Health

Prescribed Medication

Contributory Factors

Housing Future

Support Needs

Supporting Your Application

Additional Information

References

First Reference

Second Reference

Equal Opportunities Monitoring Form

Ethnic Monitoring

Disability

Consent

Application Form Author and Submit

Application Help

Required Questions

Confidentiality of Information