12. Adaptations can sometimes enable people to remain in their homes.
Please indicate with a tick whether you have, would like or have spoken to a
Social Care Occupational Therapist about the following adaptations
Have Would Like
A Social Care
approved but not
Requested from a
but not approved.
Bath hoist (xed)
Ceiling track hoist
If you have indicated that you would like certain adaptations and you have not yet spoken to a
Social Care Occupational Therapist, please contact Devon County Council, Plymouth City Council
or Torbay Council.
Please read and sign below
I give permission to the Devon Home Choice partners to:
- Contact any of the people listed on this form
- Obtain details of my medical reports from my GP or named specialist
- Seek additional information from other agencies if their advice is considered necessary.
I conrm that the details given on this application form are correct. I understand that if any
false information has been given, that this application may be refused, that any offers made
may be withdrawn, and/or any tenancies granted may be forfeited.
I/We acknowledge that it is a criminal offence to make a false statement, or deliberately
withhold information in order to seek a tenancy through Devon Home Choice. I/We understand
that members of Devon Home Choice may prosecute if an offence is committed. Please see
the Declaration on the Devon Home Choice application form for further details.
I undertake to notify Devon Home Choice of any future change in circumstances which may occur.
The personal information that you provide will be held securely. Please see the Privacy Notice
on the Devon Home Choice application form for details of how we will share or use this
information. The notice is also available at www.devonhomechoice.com
If this form is completed on behalf of someone else, or personal details or contact data about a
third party are provided, then it is your responsibility to make sure that you have informed that
person of what you have told Devon Home Choice. If you are completing this form on behalf of
someone else, please conrm whether you have a Power of Attorney to act on their behalf, as
well as your relationship to them.
This form is to be signed by the person whose health and/ or wellbeing is being affected by
your current accommodation, or lack of accommodation. Except please note that if the person
named on this form is under 16 we will need the signature of a parent/guardian. Please make
the relationship clear below.
I understand that the health and wellbeing assessment form I am completing may affect any
existing priority I have been awarded within Devon Home Choice and may result in a previous
award being cancelled. I understand that if I am awarded priority as a result of this health and
wellbeing assessment it will be reviewed regularly. This will include it being reviewed if I am
put forward for a home through Devon Home Choice.
If you are completeing this form on behalf of someone else do you
have a Power of Attorney to act on thier behalf?
Please return the completed form to the address on the front page.
click to sign
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