Ymca Housing Application Form For Supported Housing Page 3
ADVERTISEMENT
1
2
3
4
5
6
7
8How will you benefit from living in supported housing?
Doctor’s name, address and
telephone number
Time with GP:
Do you have:
Y/N
Details including who is helping you with
these needs:
-
physical health problems or
illnesses;
-
mobility requirements;
-
needs that require special
care?
Are you taking any prescribed
Y/N
Type of medication and dosage:
medication?
Have you ever had a problem with
Y/N
If yes, give details of any treatment received
and when
Alcohol?
Have you ever taken any illegal drugs or had a problem with solvent abuse?
Y [ ]
N [ ]
If yes give detail below
Substance
Tick if used
How Often Used?
Cannabis
Amphetamines
Ecstasy
Hallucinogens
Cocaine
Heroin
Crack Cocaine
Solvents
Other
If yes, give details of any help or treatment you received and when
Have you ever had a problem with
Y/N
If yes, give details
gambling?
Application/first interview - Application Form V3.1
Updated October 2010
3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business