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DARTFORD
BOROUGH COUNCIL
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Please complete the form, save it, and email it to: supported@dartford.gov.uk
Strategic Directorate (External Services)
Dartford Housing Services
SELF-ASSESSMENT
Please complete this form fully and truthfully, as the information will be used to
assess your eligibility for accommodation with an enhanced housing management
service.
Surname: _____________________________
Forename(s): _________________________
NI no: ________________________________
Current Address:
Mr / Mrs / Ms / Miss / Dr
Other:
Date of Birth: _____________
Telephone No: ____________________
Gender: Male Female
______________________________________ Postcode: __________________________
Type of Accommodation you live in now:
Flat Maisonette House Bungalow Care Home
If a flat, what floor do you live on? ____________________________________________
Would you say you are generally healthy?
Yes No
Can you see? (With glasses, if worn)
Yes With difficulty: I am partially sighted or blind
Can you hear? (With hearing aid, if used)
Yes With difficulty: I am deaf
Do the people you talk to understand what you are saying?
No Sometimes All the time
Do you have breathing problems (are you breathless) at any time?
No Sometimes All the time
Have you had any falls in the last six months?
None One More
Are you able to get involved in all the activities you enjoy, without help?
Yes No
