Title*

Forename*

Surname*

National Insurance Number

Date of Birth*

Current Address*

Type of tenure?*

Previous address?

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