Disability and/or
Medical Information Form

About this form

This form is for anyone who is applying for social housing or a social housing transfer due to a disability or medical grounds. The information provided will be used to assess if priority status should be awarded to an application

What is priority status and who we give it to

When we give a person priority status on disability or medical grounds, this means they go nearer to the top of the waiting list, as set out in the Local Authority’s Allocation Scheme

Priority status may be awarded if the following three criteria apply to your household:

• you or someone in your household has a disability or a medical condition and
• the current accommodation is not suitable to meet the needs of the person with a disability or medical condition and
• a change in housing will improve or stabilise the circumstances of the person with a disability or medical condition.

Who needs to fill out and sign each section of this form

Section 1 and 2 to be filled out and signed by the person with a disability or medical condition or by the applicant for social housing support if the person with a disability or medical condition is a dependant of the applicant.

Section 3 and 4to be filled out by two Healthcare Professionals who work with the person with a disability or medical condition.

Other information

A Healthcare Professional includes the following professions: Consultant, General Practitioner (GP), Mental Health Nurse, Public Health Nurse, Occupational Therapist and Social Worker. If you are considering using a Healthcare Professional not listed above, please contact your Local Authority to confirm if this is acceptable.

An Occupational Therapist report must be provided where there is a need for a specific accommodation requirement.

If you require extra space to complete the form please include additional pages.

Section 1: Disability and/or Medical Information

This section must be filled out by the applicant

Please tick (✓) the box to show the category you are applying under.

Disability grounds    Medical Grounds

Please state your disability and/or medical condition

If you are a person with a disability, please tick (✓) which category of disability applies to you

Physical    Mental Health    Intellectual    Sensory

Section 2: Personal Details

This section must be filled out as outlined on page 1. Please make sure the details you fill out here are the same as on your Social Housing Application Form.

Please fill in the details of the main housing applicant below.

First name                         Surname

PPS number                        Date of Birth

Declaration

I permit the Healthcare Professionals in Section 3 to give relevant medical details to the Local Authority to identify my housing needs.

Signature

Date

If the person with a disability or medical condition is not the main housing applicant, please fill in their details below

First name                         Surname

PPS number                        Date of Birth

Section 3A: Medical Reference

This section must be filled out by two Healthcare Professionals (see page 1) who work with the person with a disability or medical condition.

Details of Healthcare Professionals completing this form

Healthcare Professional 1

First name                         Surname

Name of organisation                        Telephone

Email

Please indicate the professional service you provide to the person with a disability or medical condition

Please tell us the total length of time the person with a disability or medical condition has been receiving your service

One consultation only Weeks (number) Months (number) Years (number)

Healthcare Professional 2

First name                         Surname

Name of organisation                        Telephone

Email

Please indicate the professional service you provide to the person with a disability or medical condition

Please tell us the total length of time the person with a disability or medical condition has been receiving your service

One consultation only Weeks (number) Months (number) Years (number)

Section 3B: Applicant's Current Accomodation

This section must be filled out by two Healthcare Professionals who work with the person with a disability or medical condition.

Is the person with a disability or medical conditions current accommodation directly or negatively affecting their disability or medical condition? If the answer is yes, please explain below.

Healthcare Professional 1

Healthcare Professional 2

Section 3C: Accomodation Need of Applicant

This section must be filled out by two Healthcare Professionals who work with the person with a disability or medical condition.

How would a change in location of accommodation benefit the person with a disability or medical condition?

Healthcare Professional 1

Healthcare Professional 2

What change in the type of accommodation would benefit the person with a disability or medical condition? and how?

Healthcare Professional 1

Healthcare Professional 2

What change in the design of accommodation would benefit the person with a disability or medical condition? and how?

Healthcare Professional 1

Healthcare Professional 2

Section 3D: Support Needs for the Applicant

This section must be filled out by two Healthcare Professionals who work with the person with a disability or medical condition.

Are supports currently needed to enable the person with a disability or medical condition to live independently? Please provide details.

Healthcare Professional 1         Yes       No

Healthcare Professional 2         Yes       No

Will the person with a disability or medical condition need any additional or new supports? Please provide details.

Healthcare Professional 1         Yes       No

Healthcare Professional 2         Yes       No

Section 4: Healthcare Professional Declaration

Healthcare Professional 1

I declare that the information and details I have provided on this form are correct and true.

I agree to the Local Authority contacting me, if necessary, to verify the details I have provided.

Signature

Date

Healthcare Professional 2

I declare that the information and details I have provided on this form are correct and true.

I agree to the Local Authority contacting me, if necessary, to verify the details I have provided.

Signature

Date

If you require extra space to complete the form please include additional pages.