Form completed with the client: Y/N

Client offered an interpreter: Y/N

Language required:

SUITABILITY OF ACCOMMODATION

This form is used by us when we are looking for a property to offer you. The
information you provide will help us to ensure that any property we offer you will
meet your needs.

It is your responsibility to inform us of the housing needs that you have. We

are likely to ask you to provide evidence of any statements that you make within this
form- for example proof of medical or mobility needs.

CRM Reference
number:

Main applicant name:

DOB:
National Insurance
Number:

Housing Benefit
Number:

Email and Phone

number:

Current Address:

Number of bedrooms
(property size) needed:

Benefit capped: Y / N (Date checked: )

Total amount available

to spend on rent pm: £ (Date checked: )

*If property offer more than one month from this date please ensure
that all details on the affordability assessment are correct and the
applicable amount is the same- do not assume that this form is
accurate at the time of offer without updating

Family composition
Please detail below everyone you wish to be housed with you
Name Relationship to you Date of Birth Sex

Childcare
Do you use childcare currently?
Yes No If yes please provide details:
Who provides Distance from current address Cost of childcare Reason for childcare, ie; work / study / a
current childcare? and how do they travel there break from children etc
now?

Education Needs
Do you have any Statemented/Special Needs Children?
Yes No

Details of Schools Attended by Dependent Children

Child’s Name Age Year Name of School GCSE / A
Group (If specialist school please provide Level year?
details) Specialist
school?
(Y/N)
How do they travel to school?
Public Transport Walk Car Taxi Other, please specify
How long does it take?

Social Services
Are you or any of your children known to social services?
Yes No If yes please provide details:
Name Age Social Workers name and contact number On the at Risk Register?
Yes No

Yes No

Yes No

Yes No

Yes No

Employment
Are you / anyone in your household working?
Yes No If yes please provide details:
Name and Job title and Name & Location of Work (full address), Number of hours per week
relationship to contract type Distance from current address worked
applicant (permanent / Shift patterns
How do they travel there now & at what cost?
temporary, full /
Rate of pay
zero hours etc)
Date employment started
 Caring Responsibilities
Do you / anyone in your household have caring responsibilities?
Yes No If yes please provide details:
Name, address & Distance Are they in receipt of Carer’s Allowance? How often do they care for
contact details of from current Evidence seen and attached to file? (If not receiving the person, and what do
person they care for address and Carers Allowance this could be verbal confirmation they do? (Number of times
how do they but should be recorded in notes on CRM) per week / duties carried
travel there out / times of the day they
now? visit)

Physical Health
Do you / anyone in your household have physical issues needs such as chronic disease?
Yes No If yes please provide details:
Name and Type of Medication / support / specialist support received Distance to medical services
relationship to health (evidence seen and attached to file?) provided from current
applicant problem address, and how do they
(professional travel there now?
diagnosis)
 Mental Health
Do you / anyone in your household have mental health needs (e.g. anxiety, depression, clinically evidenced
phobias)?’

Yes No If yes please provide details:

Name and Type of Medication / support / specialist support received Distance to medical services
relationship to mental (evidence seen and attached to file?) provided from current
applicant health address, and how do they
problem travel there now?
(professional
diagnosis)

Mobility
Do you / anyone in your household have mobility problems?- Please ensure client understands what this means
Yes No If yes please provide details:
Name and How far can How many stairs can they climb unaided? Do they use any mobility
relationship to they walk? aids (I.e. walking stick /
applicant scooter / wheelchair /
Zimmer frame etc), or
require adaptations in the
home? (Evidence seen and
on CRM?)

Covid
Are you or anyone in your household vulnerable to Covid 19, unable to have the vaccine, or need to shield?
Yes No If yes please provide details:
Who is vulnerable? How are you / they vulnerable Have you / they How is this impacting you / them?
(what condition causes it?) had the vaccine?

Cognitive or other health issues which may impact your housing need
Do you / anyone in your household have cognitive health needs? (this might include Cognitive Health issues, such as
Autism, Down’s Syndrome, Dementia, ADHD, Dyslexia and / or other learning disabilities. Please share details of any
diagnosis and support in place, any pending referrals with supportive organisations, and how these impact on your housing
needs)
Yes No If yes please provide details:
Name and age of Type of Medication / support / specialist support received Distance to medical services
person affected cognitive or (evidence seen and attached to file?) provided from current
other health address, and how do they
condition travel there now?
(professional
diagnosis)

Risk of violence
Are you or anyone in your household at any risk of violence or abuse? Yes No
From Whom What locations are you at risk in Details of Risk (who and what):
 FINANCIAL INFORMATION
(proof of all received income must be seen and saved to the CRM before the case will be able
to fully progress)
Are you receiving any of the welfare benefits below: Yes / No Amount *(Officer
PW use only)
(Those highlighted yellow will make the family
exempt from the benefit cap) Proof
Seen and
saved to
Support
CRM
Do you receive support from anyone this could be friends or family or a specialist service or agency like Helen
Universal
Bamber ? Credit Yes No Y/N £ Y/N
From Whom (name of person or What type of support do they provide
Housing Benefit Y/N /
and how often? (Social / Financial £ How do they currently
Y / N meet / travel to
organisation) each other- (address / place of
Practical / Emotional / Health)
Income Support Y/N £ meeting- lengthYof/ N
time journey takes /
type of transport used etc)?
ESA (Support Component)
Disability Living Allowance /PIP Y/N £ Y/N
Job Seekers Allowance Y/N £ Y/N
Incapacity Benefit / Employment Support Y/N £ Y/N
Allowance
Child Tax Credits Transport Y / N £ Y/N
DoWorking
you / anyone in the household have access to or own a car? Y / N
Tax Credits £ Y/N
Yes No
Housing Benefit Y/N £ Y/N
Do you / anyone in the household have access to a travel card?
YesChildNo
benefit Y/N £ Y/N
Maintenance Y/N £ Y/N
Carers Allowance Y/N £ Y/N
War Widows
Attendance Allowance
Industrial injuries benefit
Any other income please specify Y/N £ Y/N
Contributions from other household members (or
the amount which might reasonably be expected to
be contributed by other household members)
Y/N £ Y/N
EXPENDITURE
Car insurance £ PW £
Rent £ PW £
Road tax £ PW £
Breakdown cover £ PW £
Parking £ PW £
Bus/train fares £ PW £
Taxis £ PW £
Satellite/digital TV £ PW £
Home phone £ PW £
Internet/broadband £ PW £
Mobile phone £ PW £
Gas/Water/Electricity £ PW £
 SAVINGS AND OTHER ASSETS
Type of asset (eg saving, premium Where asset is held (eg Amount
bonds, shares) name of bank)

TOTAL SAVINGS/ASSETS

DEBTS
Debt/arrears (eg rent arrears, Who is owed the Amount
loans, Magistrates’ fines) debt/arrears

Judgement Debt

Housing Benefit overpayment

Loans

Store Cards

Credit Cards

Bank/overdraft

TOTAL DEBTS

EARNED INCOME
Are you or anyone in your household working? Y/N
Name of person Hours worked PW Salary PW Pr
working On Contract / Cash in Hand / Self Employed seen
sav
CR
£ Y
£ Y
£ Y
£ Y
£ Y

Preferences
What areas would you like to live in?

Please note we can only offer you properties which are affordable and suitable to you and available to us- we have very
limited options in Central London where properties are most expensive and sought after.

I agree that the information detailed in this form is an accurate reflection of my

discussion with my adviser:

Print
Signature
Name dated

Spouse/Partner Print
Signature Name dated