Medical Self Assessment

Only complete this form if you are already on the Housing Register


Who can apply for medical priority?

You can apply for medical priority in the following circumstances:

  1. You are already on the housing register or have applied to join the register

  2. 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 or mental health problem. We will only award priority if this risk will be reduced or removed by being rehoused or medical issues will be improved by being rehoused.

Do I need to get a letter from my doctor or hospital?

No. If we need more information from a medical professional to make a decision about your application, we will contact you and ask you to complete and sign a form which gives us permission to contact the relevant person.

How will you assess my medical priority?

You need to fill in this form so we can make a decision. If you need help, phone us on 01226 775555. We will refer your case to a Medical Assessment Officer, who may carry out a home visit to help us make a decision. We will make a decision within 10 days of receiving all the information we need.

How do you decide Housing Register priority?

Before making a decision on priority we look at your circumstances, and whether you are able to sort out your own situation. We look at whether your housing affects your wellbeing, and how you manage daily activities. We only give medical priority if rehousing will improve your health or wellbeing. There are five levels of rehousing priority – the highest is band 1, the lowest is band 5. The bands are based on the level of risk to you in your current home. If you qualify for priority, we give it from the date you asked us to consider your medical condition. We will also give you information on other housing options available to you and whether the type of property that you need is available.

What should I do if my circumstances change?

You need to let the Housing Assessment Team know. They will assess your application again and decide whether this will affect your priority.

What can I do if I am unhappy with the decision you have made?

You can appeal against our decision. When we let you know our decision we will tell you how you can appeal.


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 www.berneslaihomes.co.uk
  • 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 *

  • 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 medical need for rehousing
  • In this section you can tell us about your medical needs or the medical needs 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 medical conditions, and who need to move because of the medical conditions.
  • 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 www.berneslaihomes.co.uk

    By ticking the box below
    I/We confirm and understand that if I am in rented accommodation that you will contact my landlord for a reference.
    I confirm that all of the information I have provided above is correct. I also confirm that knowingly providing false information can affect my rights to a tenancy and could result in me losing my home if am granted a tenancy
  • I confirm that the information on this form is correct to the best of my knowledge.