Housing Application Medical Form

Latest revision date: April 2023 Revision due date: April 2025


Only complete this form if you are already on the Housing Register and if you or someone who lives with you (and who is being rehoused with you) is at risk in their current home due to a physical health problem, a mental health problem, a sensory problem or a learning disability.


How medical priority is assessed

Fill in this form and submit it to us. You do not need to get a letter from your doctor or hospital.

If you need help then telephone us on (01226) 787878 or email homeseeker@berneslaihomes.co.uk

Your case will be referred to a Housing Assessment Officer who may gather information from other professionals involved in your care. The Housing Assessment Officer may also carry out a home visit to ensure that all of the necessary information is available to them to make their decision.

A decision will be made within 6 weeks of receiving all the information and you will be notified in writing of that decision.

How medical priority is determined

Consideration is given on whether there is a medical need to move home and if any health risks will be reduced, removed or improved by being rehoused.

If you disagree with the decision.

You may appeal. You have 6 weeks, from being informed of the decision, to request a review of our decision.. To do this you may complete an on-line review form, or tell us via an email to homeseeker@berneslaihomes.co.uk or you may telephone the Housing Assessment Team on (01226) 787878.

If your circumstances change

You must let the Housing Assessment Team know by telephone on (01226) 787878 or by email to homeseeker@berneslaihomes.co.uk Your application will be reassessed to determine whether the change will affect your priority.

Protecting your personal data

By completing this form you acknowledge that we will follow our responsibilities under data protection legislation. We will store the information securely, share it with partners and other statutory agencies where we have the right under law to do this, use it only for the purpose it was provided and process it as set out in our privacy policy. For more information please see our privacy policy on our website

Please note this form only gives you one hour to complete, if you need more time simply click on the ‘SAVE FORM’ button at the end of this form.

  • About your Housing Application
  • The information in this section will help us find your housing application and update it with your medical circumstances. So we need to know the name and address of your rehousing application

  • Housing Application Number (Only complete this form if you are already on the Housing Register) *

    BERN

  • Title *

  • First Name *

  • Last Name *

  • Date of Birth *

  • Current Address *

  • If you supply us with a mobile phone number or email address this will be our method of contact with you.

  • Phone Number *

  • Email

  • About the property you live in?

  • How many steps does your property have to the main entrance door? *

  • How many steps does your property have to any other entrance *

  • Do you have any of the following in your home? *

    Please tick all that are relevant

  • How many banister rails do you have? *

  • About the person or people with need for rehousing for physical health
  • In this section you can tell us about your physical health or the physical health of other people who are moving with you. If there is more than one person you need to tell us about just press the add button at the end of this section and answer the questions about them. You don’t need to tell us about everyone in your household – just those who have a physical health condition, and who need to move because of the physical conditions.

  • About the person or people with a mental health, sensory or learning disability need for rehousing

  • Does this person have mental health, sensory or learning disability? *

  • What is this person’s condition?

  • What are this person’s symptoms?

  • Did this person’s mental health condition, sensory, or learning disability exist before they moved into their current accommodation?

  • How is the person’s mental health, sensory or learning disability made worse in their current home?

  • How long have they suffered from this condition?

  • Has this person been in hospital for this condition in the last 2 years?

  • Does this person receive treatment? (for example, medication, counselling and outpatient treatment?)

  • If so, what treatment?

  • Does this person receive support from any agencies? (for example, community mental-health team or voluntary organisation?)

  • Are they currently in hospital?

  • Name of hospital:

  • Ward number

  • Name and phone no of consultant, hospital doctor or GP

  • Name and phone no of community psychiatric nurse and/or any other professional support co-ordinator

  • What property could you and anybody moving with you manage in?
  • Please tell us here about the features you would need in any property we offer to you.

  • What sort of bathing facilities could you and other people in your household manage? Tick box all that apply *

  • What sort of access to the property could you and other people in your household manage? Tick box all that apply *

  • Inside the home, what can you and other people in your household manage? Tick box all that apply *

  • Upload Documents
  • Use this section to upload any information that may help us deal with your application for priority on medical grounds. For example a GP’s letter, a letter from the Department of Works and Pensions, or any other information.

    To upload this information you can either use a scanner or take a photo with your phone or tablet. Just click the upload button.

    More than one piece of information? Just click the “Add” button after you’ve finished uploading each one. You can upload a maximum of five pieces of evidence.

    If you haven’t got the evidence to upload at this point you can save your form until you have or you can upload it later using our “Document upload e form” which you can find on the Tell Us About it section of our website.

  • Documents of proof

    You can upload the following file types: JPG, PDF, PNG
    Please note if you are going to save this form instead of submitting, you will need to upload your file when you submit.

  • Confirmation
  • By completing this form you acknowledge that we will follow our responsibilities under data protection legislation. We will store the information securely, share it with partners and other statutory agencies where we have the right under law to do this, use it only for the purpose it was provided and process it as set out in our privacy policy. For more information please see our privacy policy on our website