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Waiting List Infomation

Waiting times depend on case classifications and may vary depending on the region of Wiltshire the prospective client lives in. However, Community 4 aim to keep their waiting times to a minimum and offer telephone support for prospective clients on the waiting list. Community 4 also provide information, advice and guidance at their area drop-ins.

Paper Application Form
Download and complete our application form, then post it to us.

Application Form (Word) (835kb)
Application Form (PDF) (118kb)

Online Application Form
Complete this form to make an application now. Agencies are encouraged to complete the application with their clients, however, an application can be submitted with the clients permission.

Part 1 of this application form is designed to be completed by or with the applicant.
Part 2 is to be completed by the referring agency.
Please complete the Initial Risk Assessment in all instances.
Incomplete applications will be returned.

PART 1	to be completed by the applicant
Applicant
Name
Address or c/o address
Postcode
IMPORTANT	In order to help us allocate this application to the most appropriate team, please tell us which area in Wiltshire you live
	North West South East
Date of birth
Please include a contact number as we will need to contact you
Gender	Male Female
Marital status	-- choose -- Single Married Separated Divorced Co-habiting Other If other, please specify:
Other people in the household (include name, gender and date of birth)
Accommodation details	-- choose -- Owner Occupier Renting Homeless Other If other, please specify:
Details of landlord or mortgage provider
Pets
If you need someone to be with you during meetings, please give details
Name
Relationship to you
Personal circumstances
1. Are you at risk of losing your home?	Yes No If yes,please give details of eviction, notice expiry or date you have to leave your home.
2. Have you recently moved or are you moving and need support to set up home?	Yes No If yes,please give moving date.
3. Are you or is any member of your household at immiediate risk of harm due to your accommodation and/or who you live with?	Yes No If yes,please give details.
4. Do you have Housing Benefit and/or Council Tax benefit problems?	Yes No If yes,please give details.
5. Do you have income, benefit and/or budgeting difficulties?	Yes No If yes,please give details.
6. Are you experiencing neighbour problems or anti-social behaviour?	Yes No If yes,please give details.
7. Do you feel you accommodation is suitable?	Yes No If no,please give details.
8. Are you experiencing debt problems, including minor rent arrears (less than 8 weeks) and/or arrears with Council Tax, water, gas, electricity etc?	Yes No If yes,please give details.
Other support
Please tell us the details (name and contact number) of any of the following people you are in contact with now or have been in the last year, using the space for 'other' if necessary.
GP/District nurse	Permission to contact? Yes No
Health visitor	Permission to contact? Yes No
Probation officer	Permission to contact? Yes No
Psychiatrist/CPN	Permission to contact? Yes No
Social worker	Permission to contact? Yes No
Other	Permission to contact? Yes No
Other	Permission to contact? Yes No
Contacting you
Please give details if there are any best days and/or times to contact you.
Other
Have you completed this form by yourself? Yes No
Do you need help with reading and/or writing? Yes No
Do you need help to understand English and/or need an interpreter? Yes No

About you
A YES answer to any of the questions below will NOT exclude you from the service, but we do need to have the answers to all of the questions to enable us to decide how we can best meet your needs
Are you currently receiving treatment for any medical condition or illness?	Yes No
Are you currently receiving treatment for any medical condition or illness?	Yes No
Do you have an alcohol/substance misuse issue?	Yes No
Do you have any criminal convictions or cases pending?	Yes No
If you answered yes to the above question do you have a conviction for assault or violence?	Yes No
Does your physical or mental health affect your daily life?	Yes No
Have you ever attempted/thought about suicide or intentionally hurt yourself?	Yes No

Is there any other information that you would like us to consider at this stage of your application?
Signature
Date
Equal Opportunity Monitoring
Ethnicity	Not recorded White British White Irish White other Mixed White/Black Caribbean Mixed White/Black African Mixed White/Black Asian Mixed other Asian/Asian British - Indian Asian/Asian British - Pakistani Asian/Asian British - Bangladeshi Asian/Asian British - other Black/Black British - Caribbean Black/Black British - African Black/Black British - other Chinese Other ethnic group Gypsy, Romany, Irish traveller Refused
Disability	Not recorded None Mobility Visual impairment Hearing impairment Progressive disability/chronic illness Mental health Learning disability Other Refused
Religion	Not recorded Christian Buddhist Hindu Jewish Musilm Sikh Any other religion Unknown Refused
	Top  Part 1  Part 2  Initial Risk Assessment  Finish
PART 2	to be completed by the referrer, with the knowledge and consent of the applicant, please also complete the Initial Risk Assessment; NOT required if this is a self referral
Referrer
Name of referrer
Referral agency
Address
Postcode
Contact number/s
Email address
Nature of involvement with applicant
What are your reasons for the application?
Are you aware of any other agencies involved with the applicant?	Yes No If so, please give details
	I confirm that I have discussed this application for housing support from Community4 with the applicant and I have their consent to apply on their behalf.
Signature
Date
	Top  Part 1  Part 2  Initial Risk Assessment  Finish
Initial Risk Assessment
Risk History
Please tick all that apply	Violence Suicide attempt/s Self harm Self neglect Arson Sexual offences Incidents involving the police Mental health difficulties Recently left prison Recently left hospital Recently left the military Abandonment Other, please specify
Risk Behaviour
Please tick all that apply	Accidental harm Alcohol use Drug use Overdose Non compliance with medication Self neglect Inappropriate sexual behaviour Violence towards workers Violence towards others Other, please specify
Are there any concerns to indicate immediate risk to self or others?	Yes No If so, please specify
Are there any concerns about potential risks?	Yes No If so, please specify
Is there information lacking or any other reason why this cannot be completed?	Yes No If so, please specify
	Top  Part 1  Part 2  Initial Risk Assessment  Finish

Data Protection

Personal data is subject to provisions of the Data Protection Act 1998. Data will not be shared with third parties unless we are required to do so by law. Data may be used to help us monitor our services. Further information will be given to you by your support worker, or see the privacy statement on this website. See our Privacy Statement for further details.