Information for applicants
Additional priority may be awarded if the information provided indicates that your current
accommodation is having an adverse effect on your health and a move to more suitable property
would considerably improve your current circumstances. Restrictions may be attached to the
type of property we will offer you such as, a ‘ground-foor recommendation’ where the applicant
will only be considered for ground foor accommodation because of their health and mobility. The
property may also require an assessment from an Occupational Therapist to ensure it is suitable
or can be suitably adapted.
Additional priority will not be awarded if your current difficulties are a result of your own
actions.
Please return your completed form via email to houreg@wigan.gov.uk
Please complete the details below of the person applying for medical priority.
Application for Rehousing
on Medical Grounds
Office Use Ref No
Date Stamp
Name
Address
Postcode
Date of Birth
Age
Mobile Telephone Number
Home Telephone Number
Email
Completing the Form
Section A - Details about you and your home.
Section B - Medical Priority.
You must ensure that you complete both sections of this form and sign the declaration.
Include as much information as possible including medication, etc.
If information is missing, we will be unable to fully assess your needs.
Section A - Details about you and your home
1. If you live in a flat, is there a lift in the building?
2.
3. Where is your toilet? (please tick one or more boxes)
4. Where is your bathroom? (please tick one or more boxes)
5. Where is your bedroom?
6.
7.
8.
9.
1
No
Yes
How many steps are there at your front door entrance?
Upstairs
Downstairs Same Floor
Outside
Upstairs
Downstairs Same Floor
Upstairs
Downstairs Same Floor
Number of bedrooms in your current property
Number of bedrooms available to you
How long have you lived at this address?
If you are lodging or have no fixed abode please explain why you left your last settled
address
10. Please give details below of your last address detailing when you left & the type of tenure.
Address Date left Tenure type, e.g.
renting, owner, etc.
11. What areas are you requesting to move to? Please state the part of Wigan Borough by area
name e.g. Scholes, Howe Bridge, Marsh Green, Higher Folds, Atherton etc.
12.
13a. Have you ever served in the Armed Forces?
2
Please give any specific details of the property type or location of the accommodation you are
looking for, if you are moving to be closer to family support please give address of who you wish
to live closer to.
No
Yes
b. If ‘yes’ please give details
c. If you or your partner are serving or have formerly served in the Armed Forces, please
provide details of your service number
Section B - Applying for Medical Priority
1. Please give details of all your medical condition(s) below
Medical condition How long have you had this condition?
2. Please refer to your prescription for assistance in completing this section.
Please list the details of any medication you are taking including the dosage or attach a copy
of your repeat prescription showing the details of your medication.
Medication Dosage
Please complete questions 1 & 2 in full.
Without this information we will not be able to assess your application.
3
3.
4
Please tell us why your current accommodation does not meet your housing needs and how
your health or wellbeing would improve if you moved to different accommodation
4. Mobility
Do you use any of the following and how often? (please tick one box for each)
Walking stick
Zimmer frame
Crutches
Wheelchair indoors
Wheelchair outdoors
Motorised scooter
Motorised wheelchair
5. Do you have any adaptations in your home?
If ‘Yes’, please indicate details below.
6. Have you applied for any adaptations?
7.
Please note that if an Occupational Therapist has assessed your current home and has agreed adaptations
but you have refused this work as you prefer to move, then we will take this into consideration when we
assess this application. This may result in you not being awarded further priority.
5
never
sometimesoftenalways
Shower Stair Lift
Through-Floor Lift
Ramp Hoist
Other
Other, please detail here
If ‘No’, why not?
If ‘Yes’, (a) when did you apply?
(b) who did you apply to?
What was the outcome?
never
sometimesoftenalways
never
sometimesoftenalways
never
sometimesoftenalways
never
sometimesoftenalways
never
sometimesoftenalways
never
sometimesoftenalways
NoYes
Yes No
8a. Would you stay in your current home if it could be adapted to suit your needs? (for example,
grab rails or stair-lift)
8b. Have you been assessed by an Occupational Therapist?
Please note that we may forward your application to the Council’s Occupational Therapy
Team to see if they can help you to stay in your current home.
9. What adaptations would you require in your new home?
10. If you use a wheelchair, do you require assistance to transfer from your wheelchair to other
equipment/furniture?
11. Do you use any specialist equipment, for example, a commode or a bath hoist?
If you do, please write details below
12. Do you require low level facilities?
13. Can you use the stairs? (please tick one box)
14. Can you wash and dress? (please tick one box)
15. Shopping, Cleaning and Cooking (please tick one box)
6
NoYes
If ‘No’ why not?
NoYes
NoYes
NoYes
Not at allWith helpOn your own with difficulty
On your own easily
With helpAlone
With helpAlone
16. Do you have regular visits from?
17. Please list their name, address & contact telephone number below.
18. Do you have a carer?
Does your carer live with you at the moment?
Do you need an extra bedroom for your carer?
Does your carer receive Carers' Allowance?
7
District Nurse
Home Care Worker
Social Worker
Community Mental Health Team Worker
Health Visitor Occupational Therapist
Other, please specify
How often do they visit you?
NoYes
NoYes
NoYes
NoYes
Please provide full details of your carer, name, address, telephone number & relationship to you
19. Do you receive any benefts because of your disability?
If you have any social care needs, or feel that you would benefit from an
assessment, please contact Wigan Council’s Central Duty Team
Tel: (01942) 828777 to see if you are entitled to assistance
20. Please write the name, address and telephone number of your doctor below.
8
NoYes
If ‘Yes’, please write details below
Declaration
I understand that Wigan Council may need to contact other agencies for information about me
so that they can process my application. Wigan Council need my permission before they can
do this. This could include Housing Benefts and Council Tax, other landlords, the Benefts
Agency, Probation Service, the Police and Social Services. Wigan Council may not be able to
process my application without this information.
I give permission for Wigan Council to contact any relevant agencies, including my present
and/or former landlord. I give these agencies permission to share any information they hold on
me with Wigan Council so that they can deal with my housing application.
I understand that Wigan Council will only use any information they get from other
agencies to deal with my application.
I understand that Wigan Council may share any information they hold on me with various
Council departments and other organisations that deal with public funds to prevent and detect
fraud.
The information I have given on this form is correct. I understand that if I have given any false or
misleading information on this form I could be evicted from my new tenancy.
Applicant
Joint Applicant
9
Signed Date
Signed Date
This information can be made available in large print or other formats. Please
telephone 01942 489005 for more information.
People with hearing difficulties who have a Minicom can contact us through the
typetalk operator by putting 18001 in front of any of our telephone numbers.
The following phrases say:
If you do not read or speak English and need help understanding this information
please leave a message on our community language line and an interpreter will
ring you back.
Francais - Si vous ne pouvez pas lire ou parler l’Anglais et avez besoin d’aide pour
comprendre ces informations, veuillez laisser un message sur la messagerie
téléphonique de notre service Linguistique en Ligne (Language Line) au 01942
488433 et un interprète vous rappeller
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