Application for Rehousing to Receive Support

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

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

Who should complete this form?

Anyone who is already on the Housing Register, or has completed an Application Form to join the Housing Register, and who needs to receive support from someone who does not live with them. We will award priority to those people whose current housing situation is affecting their ability to receive support. This includes where the distance between the home of the person providing the support and the home of the person receiving it affects the ability to give the support needed.

You should not complete this form if you are currently living with the person from whom you receive support.

How priority for receiving support is assessed

Fill in this form and submit is 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

Your case will be referred to a Housing Assessment Officer who may contact you to get more information. The Housing Assessment Officer may also carry out a home visit to ensure that all the necessary information is available to them to make their decision.

We aim to carry out assessments within 10 days of receiving all the information we need and you will be notified of that decision in writing.

What will the assessment include?

We will consider what need there is to receive support including:
• how far you/they have to travel and how often;
• what transport (public and private) is available;
• how much other support there is;
• the other commitments of the person giving support

If you disagree with the decision

You may appeal. You have 6 weeks, from being informed of the decision, to register an appeal. To do this you may complete an on-line Appeal Form, or tell us via an email to or you may telephone the Housing Assessment Team on (01226) 787878.

If your circumstances change

You must let the Housing Assessment Team know by completing a Change of Circumstances Form on the Berneslai Homes website or by telephone to (01226) 787878 or by email to Your application will be reassessed to determine whether the change will affect any 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 the applicant who is moving to receive support
  • Your title *

  • Your first name *

  • Your last name *

  • Your address *

  • Your date of birth *

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

  • Your e-mail address

  • Your application reference number *

  • Do you work? *

  • How many hours a week do you work?

  • What days of the week do you work?

  • Tell us the address of your place of work

  • About the person you are receiving support from
  • Their title *

  • Their first name *

  • Their last name *

  • Their address *

  • Their date of birth *

  • Their phone number *

  • Their e-mail address

  • What is your relationship to them? *

  • Does the person work, who gives you support? *

  • How many hours a week do they work?

  • What days a week do they work?

  • Tell us the address of their place of work.

  • Your support needs
  • Tell us why you need support *

  • What extra support will you get if you moved nearer? *

  • Tell us about any other support you get from any other person/agency (if any), include here the type of support and who gives the support. *

  • Do you receive any of the following?
  • Attendance Allowance *

  • Disability Living Allowance (DLA) or Personal Independence Payments (PIP) *

  • If yes, which rate?

  • Does the person giving you support (or anyone else) receive any benefit allowances for looking after you? *

  • If yes, tell us what allowance they receive.

  • The support you receive
  • Please tick which of the following types of support you currently receive from the person/s you want to move nearer to (tick box all that apply)

  • Please give details:

  • Do you travel to receive support or does the person who supports you travel to you? *

  • How often do you get support from the person/s you want to move nearer to? *

  • How do they/you travel? (please tick all that apply) *

  • How far do they/you travel? (Please tick the answer which best describes your journey) *

  • What difference would it make for the person/people who give you support, if you lived nearer? *

  • Do you get support from anyone else? *

  • Please tell us who they are and what support they give you

  • Confirmation
  • By ticking the box below, I declare that I fully understand and agree with the following statements:

    - I declare that the information I have given on this form is correct and complete. 

    - I understand that if you later find that I have deliberately supplied false information or omitted to supply information, this can affect my rights to a tenancy and you may take action against me if I am granted a tenancy.

    - I understand that if I have not completed this form fully it may result in a delay in us acting on your request.

    - I understand you may share my information with other agencies to detect and prevent fraud.

    - I confirm that I have already completed a housing application form.
  • *