Guidance On Applying For Priority Rehousing On Medical Grounds (Page 2 of 5) in pdf

Guidance On Applying For Priority Rehousing On Medical Grounds Page 2

PRIORITY REHOUSING ON MEDICAL GROUNDS

IN MEDICAL CONFIDENCE

Surname:

Mr/Mrs/Ms/Miss

First name(s):

Home Address:

Post Code:

Home Phone Number:

Ethnic Group

1.1

Did anyone suggest you apply for priority on medical grounds?

Yes

If you answered Yes, who suggested you apply?

Housing Officer: ________________________________

Telephone No. ______________

Health Visitor: __________________________________

Telephone No. ______________

Social Worker: __________________________________

Telephone No._______________

Other: _________________________________________

Telephone No. ______________

Have you been assessed by an Occupational Therapist?

Yes

Have arrangements been made for you to be assessed by an Occupational Therapist?

Yes

1.2

Who is the family doctor of the person who has the medical condition(s)?

Name:

Dr.

Address:

1.3

Does the person with the medical condition(s) receive any of the following services?

Home Help

District Nurse

Other (please specify)_______________________

1.4

Is the person with the medical condition(s) currently in hospital?

Yes

If you answered Yes, please complete the following:

Hospital Name:

Date of Admission:

Consultant in Charge:

Guidance On Applying For Priority Rehousing On Medical Grounds Page 2