National Insurance Number
Date of Birth*
Type of tenure?*
CouncilHousing AssociationLiving with parentsOwner OccupierSharing AccomodationSupported HousingPrivately rented
Approximate Household Income
Would you consider yourself to have a a disability?*
If yes please give details of your disability
Do you have a serious, ongoing medical condition?*
If yes please give details of your medical condition
Are you known to the Community Mental Health Team?*
If yes, who is your case worker?
Have you been released from a custodial sentence within the last month?*
If yes please state what date you were imprisoned and what date you were released?
Are you on a rehabilitation order or probation order?
If yes please provide details?
Are you recently discharged from the Armed Services? Have you been a member of the Armed Forces?*
If yes please provide details
Have you ever been in care? *
If yes name of the authority that placed you?
Number of dependent children under the age of 16?*
Are you expecting a baby?*
If yes, expected due date
Have you approached Castle Point Borough Council Homelessness or Housing Advice before?*
If yes please give details
Are you on the Housing Register?*
Please enter the details of your current enquiry here. Please note the more details you can provide us with will enable us to deal with your enquiry quickly*
Please provide your mobile number*
Please provide your landline telephone number
Please provide your email address