Accommodation Online Application Form

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Accommodation Online Application Form

Fill out this form to apply for a place in our hostel.

Please be as honest as possible as this will help us to support you. If you need any help completing this form, call us or drop in to one of our hostels.

Fields marked with * are required.

Nottingham Hostel
4 Shakespeare Street
Nottingham
NG1 4FG
0115 956 7600

Mansfield & Ashfield Hostel
57 Commercial Gate
Mansfield
NG18 1EU
01623 407 801

Your information:

Date of application (DD/MM/YYYY): *

First name: *

Surname: *

Date of birth (DD/MM/YYYY):

Place of birth:

NI number:

Email address:

Contact number: *

Gender:

Male

Female

Ethnicity:

If other, please specify:

Reason for application:

Your reason for application:

If other, please specify:

Referral source:

Your referral source:

If other, please specify:

Support needs:

Please select all that apply:

Alcohol related problems
Drug related problems
Frail elderly
Learning difficulties
Mental health problems
Leaving penal establishment
Physical long term illness
Refugee or asylum seeker

Single homeless needs support
Finances
Living skills
Personal hygiene
Finding work/education
Domestic violence
Young at risk or leaving care
Other

If other, please specify:

Are you pregnant?

Yes

If yes, what stage of your pregnancy are you at?

Current situation:

What is your main source of income?

If other, please specify:

Have you experienced any problems in the following areas/or at risk of any of the following?

Risk	low risk	medium risk	high risk
Mental Health Problems
Violence
Domestic Violence
Alcohol Abuse
Substance Misuse
Sexual Abuse
Crime Related Issues
Long Term Illness
Disabilities
Gambling
Other

Please provide more details:

Convictions

	Arson		Drink/drug related
	Sex offences		Burglary
	Violence/harassment		Criminal damage
	Weapons		Offences against minors or the vulnerable

Please provide more details:

Are there any known incidents of physical violence?

Yes

If yes, what relationship did you have to this person?

What was the severity of the incidents?

Minor injury

Serious injury

Death

What is the occurrence of this?

Sanctioning

Have your benefits been sanctioned in the past?

Yes

If yes, what is the reason for this?

Are you currently sanctioned?

How long are you being sanctioned for?

Support

Are you involved in any activity with any support agencies?

	Name of Worker	Address	Contact Number
Probation
Youth support
Drug services
Alcohol services
Mental health services
Outreach services
Floating support

Do you have any criminal convictions?

Yes

If yes, please give details:

Do you have any spent or pending convictions?

Yes

If yes, please give details:

Are you on any of the following?

Bail

Parole

Licence

If you have said yes to any of these, please give details:

Previous addresses

Previous Address 1

Address:

Type of accommodation eg sofa surfing:

Date from:

Date to:

Reasons for leaving:

Previous Address 2

Address:

Type of accommodation eg sofa surfing:

Date from:

Date to:

Reasons for leaving:

References

Title:

First name:

Surname:

Contact number:

Address:

Relationship to application:

Email address:

Next of kin contact information / person of contact

Reference 1

Name:

Address:

Relationship to applicant:

Contact number:

Email address:

Reference 2

Name:

Address:

Relationship to applicant:

Contact number:

Email address:

Registered Charity 243044 \| VAT 117 2061 10 \| RSL H3286 \| Registered Office 4 Shakespeare Street, Nottingham NG1 4FG Company Limited by Guarantee, Registered in England and Wales-Registered 310342	by Serosensa

Accommodation Online Application Form

Fill out this form to apply for a place in our hostel.

Fields marked with * are required.

Name of Worker

Address

Contact Number