Update March 2015
This version is intended if you are filling in the form electronically, throughout
the form you will find highlighted areas that indicates where you may submit
your answers.
Medical Assessment
and
Social Care Needs
Assessment
E-Form March 2015
Applicant’s Full Name…………………………………………………
Kent HomeChoice Number……………………………………………
This version is for use if you are filling in the form electronically. Throughout the form you will
find highlighted areas that indicate where you should enter your answers. Once complete you may
print your document and then post it to us or save your document and email it to us.
IMPORTANT NOTICE
PLEASE READ BEFORE FILLING IN THIS FORM
You will need to supply supporting documents as evidence of any statements
regarding your medical conditions that you make on this form.
It is your responsibility to provide this evidence or seek it from your healthcare
professional
Evidence can be in the form of supporting letters or details of medication, e.g.
copies of prescriptions. Please be as thorough as possible.
If you do not supply this information we may not be able assess your case
GUIDANCE
Guidance for completing this form
Please tick which category best describes your circumstances:
Your home is unsuitable for your needs and you want us to take into
account your medical condition which is being made worse by your
current housing (please complete parts A, B, C, D, F and G)
You need to move to a particular locality in Dartford where failure to
meet that need would cause hardship to yourself or others (please
complete parts A, E, F and G)
Both of the above (please complete all sections)
Please note medical priority is not routinely given for the following:
anxiety, stress or depression
asthma
ADHD, OCD, personality disorders and other behavioural problems
pregnancy
epilepsy
short term illness or injury
fear of lifts or concerns over lift reliability
drug and/or alcohol dependency
Details of your medical condition/social care needs and your current housing
will be taken into account before we decide on the level of priority on medical
or social care grounds. The Council’s Allocations Policy has further details on
how priority is assessed.
Please complete each relevant part of the form, tick the checklist to make sure
you have completed everything and sign the declaration at the end. Send it to
us, together with your supporting evidence to:
Housing Register
Dartford Borough Council
Housing Options and Private Sector Team
Civic Centre
Dartford
Kent DA1 1DR
You can also email the form and supporting evidence to
allocations@dartford.gov.uk or bring it to the Civic Centre marked for the
attention of the Housing Options and Private Sector Team.
If you need help to complete the form or would like it in another format please
contact us on (01322) 343907
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P
A
R
T
B
P
A
R
T
A
Part A
Personal details
Details of household member to be assessed:
Surname ………………………… First name(s) ………………………………...
Male Female Date of birth ………………………………....
Address…
Post code
Telephone Number: Home …………………….. Mobile …………………………
Email……………………………………………………………………………………
Part B
Medical Details
1. Details of your medical condition
Please give details of all of your medical conditions and treatments in
the table below.
Medical
Condition
Date of
diagnosis
Name of medication
and dose
How often
do you take
this
medication?
2 -
circle)
…………………………………………………………………………………………
…………………………………………………………………………………………
……………………………………………………………………………….…………
………………….………………………………………………………………………
2. Are you currently receiving hospital treatment for your medical
condition?
Yes / No (please
click on the correct answer)
If Yes, please give details:
3. Are you awaiting further investigation / hospital referral / surgery for
your medical condition?
Yes / No
If Yes, please give details:
4. Your medical condition and current housing
What type of property do you live in? (please tick)
Flat on ground
floor
House
Flat above
ground floor
B&B/Hotel/Other
Temporary
accommodation
Maisonette Hostel/night
shelter
Bungalow
Other (please specify) ………………………………………
How many bedrooms do you have? ..……………………...
What floor do you live on? ...………………………………..
Is there a lift(s)? Yes / No
Are there any stairs within your home? Yes / No
If Yes, how many? ….........
Are there any stairs or steps outside the door to your home? Yes / No
If Yes, how many? ….........
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Please explain how you think your medical condition is being made worse by
your current housing. (This MUST be completed in order for your application
to proceed)
5. Your mobility
Can you walk independently (without using a walking stick/frame)? Yes / No
If Yes, please go to Part C: Further information.
If No, do you use a walking stick / walking frame /crutches / other?
……………………................................................................................................
Do you have difficulty climbing one flight of stairs (e.g. 14 steps)? Yes / No
Do you have difficulty climbing one or two steps? Yes / No
Do you use a wheelchair? Yes / No
If Yes, please circle whether this is:
a) Occasional use outdoors? Yes / No
b) Occasional use indoors? Yes / No
c) Full time use? Yes / No
Are you registered disabled or blind? Yes / No
If Yes, please state registration number: …………………………………………..
Do you have any adaptations to your home due to your disability? Yes / No
If Yes, please state what these adaptations are:
…………………………………………………………………………………………..
If No, please give details of any adaptations that you may need:
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Yes / No
P
A
R
T
D
P
A
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T
C
Part C
Further information
1. Can you carry out the following tasks without help from someone
else?
a) Use a bath Yes / No
b) Cleaning/housework Yes / No
c) Shopping Yes / No
d) Cooking Yes / No
If you have answered No to any of these, please tell us what help you need
and who helps you:
2. Does your medical condition affect you in your day to day/social life?
Yes / No / Not applicable
If you ticked Yes, please explain how it affects you
Part D
Kent County Council Housing Needs Assessment
If you have a physical disability and you feel your home is no longer suitable
you will need to be assessed by an occupational therapist (OT) from Kent
County Council’s Assessment and Enabling team before your application can
proceed. This will count as supporting documentation.
Please call the following numbers to arrange your assessment.
Adult OT team – 03000 416161
Children’s OT team – 03000 413232
Please make sure you submit the COMPLETED Housing Needs
Assessment with this document.
Have your needs been assessed by an OT?
Name of OT worker: ………………………………..
If Yes, what date were you assessed? ………………………………………
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P
A
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T
E
Part E
Social Care Needs
This section is for people who may need to move because of social care
reasons. Our Allocation’s Policy gives reasonable preference to people who
need to move to a particular locality in Dartford, where failure to meet that
need would cause hardship to themselves or others, for example to give or
receive care.
This part MUST be completed if you are applying on the above grounds.
1. If you feel you need to move because otherwise it would cause
hardship to you or others, please explain why this is the case here.
If you need to move to give care to someone, please state their name and
relationship to you.
Name……………………………………Relationship………………………………
If you need to move to receive care from someone, please state their name
and relationship to you.
Name……………………….……………Relationship….……….…………………
Where do they live? (please give full address and telephone number)
2. If there is there any other information you would like us to consider
in relation to your social care needs please tell us here.
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P
A
R
T
F
Part F
GP/Support Worker details
3. Details of your GP and any other support workers
Please complete your GP details:
1. Name of your GP/Doctor
Full address
Telephone Number
Please list any other support workers involved in your care:
1. Name
Address
Telephone number
2. Name
Address
Telephone number
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P
A
R
T
G
Part G
Declaration
Before you return this form, please sign the declaration below. In all cases, the
household member with the medical or social issue must sign the declaration.
If this person is under 18 years of age, then their parent or legal guardian
should sign in their place.
Please remember it is up to you, as the applicant, to provide medical
evidence.
I confirm that the information provided on this form is true, and that I will inform
Dartford Borough Council if there are any changes in my medical condition or
housing needs. I give my permission for my doctor / hospital consultant / other
health professional / support worker to give details about my health and
support needs, related to my application for rehousing, to Dartford Borough
Council’s housing medical/welfare panel.
Full name……………………………………………………………………………...
Signature………………………………………Date ……………………………….
Parent / Guardian of ………………….………………………………………..
If this form has been completed by anyone other than the applicant, please
give details below:
Completed by……………………………………………………….(PRINT NAME)
Signed…………………………………………………………………………………
Relationship to applicant…………………………………………………………….
Contact Number………………………………………………………………………
If you intend on submitting this form by email please check here :
if you agree to the above declaration and are unable to insert your signature.
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FINAL CHECK
Final Check
Before you submit this form please check and tick the
following:
Have you made an on-line application for housing?
You must register with us before we can carry out a medical
assessment. Go to www.kenthomechoice.org.uk to register
Have you completed the sections that MUST be completed in order for
your application to proceed?
Have you had a Housing Needs Assessment by an OT (If applicable)
and is it attached?
Have you included your supporting evidence?
Have you added your Kent HomeChoice number to each page of your
supporting documentation?
You may either print this form out and return to the address on page 1 of this form
or you may save the form and email it to allocations@dartford.gov.uk
Data protection statement
By signing this form you agree to the following statement:
‘I am aware that the Council will create and maintain computer and paper
records on me and that these records will be processed in accordance with the
Data Protection Act 1998 and may be used for the purposes described in this
assessment both internally and to external organisations/bodies’.
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