Housing Application Support Information

Complete this form only if you have been advised by your GP. If you have submitted a housing application the council may ask your GP for more information to support your application. Providing detailed information will help with your application.

Last Updated: 11/02/2024

Your Details

Full Name

Date of Birth

Mobile Number

Email Address
Your Information

What is your medical condition(s)

List any medication you are taking for your condition (optional)

Provide details of any counselling or therapy you are having (optional)

Is your condition currently managed

Are you under a specialist? If so provide further details (optional)

How does your current accommodation significantly impact your condition

How does your medical condition impact your day to day activities

Please explain how a move to alternative accommodation would improve your medical condition

What type of accommodation would be suitable

Could anything be done to help improve your condition, whilst remaining in your current accommodation
Consent

This form collects your name, date of birth, email, other personal information & medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you & also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

*

I consent to the practice collecting and storing my data from this form.

I consent to the practice sending me text messages concerning my direct medical care

I consent to the practice sending me emails concerning my direct medical care & practice information

I consent for a GP to use this information to compile a report

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Housing Application Support Information

Your Details

Your Information

Consent