Ymca Housing Application Form For Supported Housing Page 2
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8What is preventing you from living at
Landlord’s name, address (if not living at
home?
home)
Name, address and telephone number
Previous Addresses (since leaving permanent
of next of kin
home)
Reason for Application
Living in overcrowded accommodation
Harassment
Please tick which best describes your
Health or medical reasons
reason for applying to YMCA Housing
Poor housing conditions
Financial difficulties
Breakdown of relationship with
Evicted
partner
Need for independence
Need for higher level of support
To move out of shared housing or
Discharged from long stay institution such as
hostel
prison or hospital
To be near family, friends or
To move out of temporary accommodation
employment
Required/asked to leave home
Homeless
Other reason – Please state
Domestic Violence
Source of Referral
Referred by College
Please let us know who pointed you in our
Referred by statutory agency e.g. social
direction
services, YOT
Referred by Fylde or Wyre Borough
Referred by voluntary agency e.g. Face to
Council
Face, Streetlife, CAB, Pierpoint
Self referral
Another housing association
YPS/Connexions – name of PA
Other – please state
What is the total money you get each
week after deductions?
What is the source of your income
State whether from work or type of benefit
Are you in any debt?
If yes, how much do you owe and to whom?
Application/first interview - Application Form V3.1
Updated October 2010
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Parent category: Business