Ymca Housing Application Form For Supported Housing Page 4
ADVERTISEMENT
1
2
3
4
5
6
7
8Have you ever attempted suicide?
Y/N
If yes when was last time?
How many times in total?
If yes when was last time?
Have you ever intentionally hurt
Y/N
yourself?
How many times in total?
Have you every behaved aggressively
Y/N
How often does this happen?
or violently?
When was last time?
Did you hurt someone/damage someone’s
property?
Have you ever accessed mental
Y/N
If yes, give details including brief history, any
treatment and any diagnosis
health services or seen a counsellor?
If yes, include name, contact details and date
Do you have or have you ever had a
Y/N
Psychiatrist or other professional
helping you with mental health
issues?
If yes, give details
Are there any other medical/health
Y/N
issues not already covered?
Have you ever been convicted of a
Y/N
If yes, give details including number of
convictions and any cases still pending
criminal offence or received a caution
or ASBO?
If yes, give details
Have you ever been convicted of a
Y/N
sex offence, or an offence of a sexual
nature, including indecent assault?
Are you currently on the Sex
Y/N
If yes, give details, including length of time on
the register and time remaining
Offenders Register?
If yes, give details
Are you currently under a supervision
Y/N
Probation or Y.O.T. Officer’s Name:
order or probation order?
:
Office
Tel. no.
Have you ever been in care or have
Y/N
If yes, are you currently under a care order?
any of your dependents had
Social worker/leaving care worker:
involvement with Social Services or
been subject to a child protection
Address/Tel. no:
order? If yes, please provide details
including social worker / leaving care
worker
Application/first interview - Application Form V3.1
Updated October 2010
4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business