1. Family have asked me to leave	7. Care leaver
2. Family relationship has broken down	8. Evicted from tenancy
3. Overcrowding	9. Harassment
4. Family moving / moved	10. Bereavment
5. Abuse / Violence at home	11. Living in hostel / B&B
6. Prison leaver

12. Other Please explain

Name Of Organisation		Contact Name
Address		Telephone
Support given

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Name Of Organisation		Contact Name
Address		Telephone
Support given

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Name Of Organisation		Contact Name
Address		Telephone
Support given

> 1. Completing Forms	> 5. Life Skills
> 2. Budgeting	> 6. Drug / Alcohol use
> 3. Cliaming benefits	> 7. Health Issues
> 4. Making Friends	> 8. Training Employment

9. Other Please explain



What is Your Current Income?

Do you have any health problems or disabilities
Yes No

If yes, please explain



Where do you whish to be housed

Stockton Middlesbrough Thornaby

Do you have or are you expecting a child that would be permanently housed with you?
Yes No

Name Of Worker

Agency

Address

Town

Postcode

Telephone Number

Risk assment Completed
Yes No

N.B. We will normally write to you to advise you of the date and time of the interview and also the outcome of the interview. If you require any further information please do not hesitate to telephone us and we will be pleased to share information, provided we have the applicants permission.

If the applicant is housed in the futre do you whish to be involved in the support planning process
Yes No

How long do you expect to be working with this young person?

Please state why you feel that this person needs supported accommodation