Version: H&W April 2016
Have any questions about this form
Would like help lling the form in
Need this document in a different format (e.g. large print)
Require any further support
Please note that the Devon Home Choice partners will not make any payment for
the Supporting Evidence form to be completed.

  
 
3. Please name the condition(s) you, or anyone else who needs to be rehoused with you,
suffer from. Please only give details of conditions that are affected by your current
accommodation (E.g. that affects your ability to remain in, access or move around in
your home etc)
Other
Please provide details of your doctor
Name
Phone number
Please do not give details of conditions that are not affected by your accommodation or
could not be resolved by moving to a new home.
Condition 1
Please name this condition:
How does your current accommodation impact on this condition?
How do you currently manage this condition in your current accommodation? (E.g. are there stairs
you cannot manage, have you had any falls, are there essential facilities in the home that you are
unable to access, is your mental health adversely affected etc.?)
Do you take medication for this condition? Yes No
If Yes, please provide details (e.g. the name and dosage of any medication)
Has your GP referred you to a specialist for this condition? Yes No
If Yes, please provide their:
Name
Role (e.g. occupational therapist, consultant, mental health worker etc.)
Phone number
3
2
If‘No’pleasegotoQ13
6.
7.
8.

 
 
  
 
Condition 2
Please name this condition:
How does your current accommodation impact on this condition?
How do you currently manage this condition in your current accommodation? (E.g. are there stairs
you cannot manage, have you had any falls, are there essential facilities in the home that you are
unable to access, is your mental health adversely affected etc.?)
Do you take medication for this condition?
If Yes, please provide details (e.g. the name and dosage of any medication)
Yes No
Has your GP referred you to a specialist for this condition?
If Yes, please provide their:
Name
Role (e.g. occupational therapist, consultant, mental health worker etc.)
Phone number
Yes No
Condition 3
Please name this condition:
How does your current accommodation impact on this condition?
How do you currently manage this condition in your current accommodation? (E.g. are there stairs
you cannot manage, have you had any falls, are there essential facilities in the home that you are
unable to access, is your mental health adversely affected etc.?)
Do you take medication for this condition?
Yes No
If Yes, please provide details (e.g. the name and dosage of any medication)
Has your GP referred you to a specialist for this condition? Yes No
If Yes, please provide their:
Name
Role (e.g. occupational therapist, consultant, mental health worker etc.)
Phone number
Condition 4
Please name this condition:
How does your current accommodation impact on this condition?
54
  
 
 
 
 
How do you currently manage this condition in your current accommodation? (E.g. are there stairs
you cannot manage, have you had any falls, are there essential facilities in the home that you are
unable to access, is your mental health adversely affected etc.?)
Do you take medication for this condition? Yes No
If Yes, please provide details (e.g. the name and dosage of any medication)
Has your GP referred you to a specialist for this condition?
Yes No
If Yes, please provide their:
Name
Role (e.g. occupational therapist, consultant, mental health worker etc.)
Phone number
4. Do you have a carer?
Yes No
If ‘Yes’, is your care?
(Please tick all that apply)
Formal (e.g. a paid carer)
Informal (e.g. provided by a family member or friend)
Live-in
3 times a week or more
Twice a week or less
Please provide your carer’s name and contact details:
Name
Phone number
Address including postcode
6
7.
8.
9.
10.
11.
5. What help does your carer provide?
Personal care
Shopping for food
Preparing food
Giving medication
Paying bills
Attending appointments
Other (please detail)
6. Do you have any mobility problems or needs?
Yes No
If ‘No’, please go to Q12
7
11.
23.
24.
8 9
 

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
Occupational
Therapist has
approved but not
yet completed
Requested from a
Social Care
Occupational
Therapist
but not approved.
Bath hoist (xed)
Ceiling track hoist
Downstairs toilet
Dropped kerb
Handrails or
Grab-rails
Lowered kitchen
surfaces
Parking bay
Access Ramps
Stairlift
Step-lift
Through-oor lift
Upstairs toilet
Widened doorways
Showering facility
(please detail)
Other
(please detail)
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
Authorisation
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.
Declaration
I conrm 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.
Privacy Notice
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 conrm whether you have a Power of Attorney to act on their behalf, as
well as your relationship to them.
Important Note
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.
Signed
Date
Full Name
Relationship
(if applicable)
If you are completeing this form on behalf of someone else do you
Yes No
have a Power of Attorney to act on thier behalf?
Please return the completed form to the address on the front page.
9
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome