Home Medical Referrals Medical Referral form

Application for priority rehousing on medical grounds

Please be aware that the support team are currently receiving a high volume of medical applications and there is a waiting list for assessments. Assessments will take place in order of date received and you will be contacted once yours is due. 

You must be registered with HomeLink before you make an application.

Please be reassured that if your application is successful and you are awarded priority rehousing on medical grounds it will be from the date we received your application and all supporting information to enable us to make an assessment.

Please answer every question, giving as much information as possible.

In order to process your application you must include at least one of: a contact telephone number, email or contact home address on your application.

Please be aware that medical priority can only be awarded to those who are 'chronically sick or severely disabled who cannot live independently in their home or manage the access to it'. 

While you may have a serious medical condition, we assess on the extent to which this affects your mobility within your home and your ability to manage the access to it.

***For those applying for priority rehousing on mental health grounds, please do not complete this form. If you meet the criteria for priority rehousing on mental health grounds, then a firm recommendation should be submitted by a community psychiatric nurse or other mental health NHS professional only and sent to the HomeLink Support team by the NHS.***

 

 

Application for priority rehousing on medical grounds

1 General Information
You need to be registered with HomeLink to be able to complete this form
Your Title
Your Gender
dd/mm/yyyy
Do you have a partner who will also need to complete this form?
2 Property Details
What type of tenancy are you currently occupying?
What kind of home do you live in?
3 Facilities
Where is your toilet located? Select all that apply
Where is your bathroom located? Select all that apply
Does your home have central heating?
Is access to your home...
Have you ever been involved with the occupational therapy department?
Does your home have any of the following adaptations? Please select all that apply
Do you have a social worker?
Do you have a hospital consultant?
4 Present Allowances
5 Support
Do you receive any support, for example, meals on wheels, community care or help from your family?
6 Medical Conditions
Give as much detail as you can
Does your illness require regular treatment by the hospital or your own doctor?
Do you use a wheelchair?
Can you get in and out of your home?
Can you go to the toilet by yourself?
Can you get to the bathroom by yourself?
Can you stand and sit?
Can you walk?
Can you climb stairs?
In some cases we may need to contact your doctor for more information about your medical condition. Is this okay?
7 Equal Opportunities Monitoring

Please help us to monitor the service we provide and the way we treat applications by completing the details below. We need this information to make sure that everyone receives fair and sensitive treatment according to their needs. We will keep information confidential.

What happens next

When we receive your completed application, a member of the HomeLink support team will put your application on a waiting list for assessment. Waiting times may vary, depending on the number of applications received. Please be assured that we will contact you once it has been assessed – you do not need to contact us. Before pressing submit, please check you have provided your correct contact details and you’ve provided as much information as possible about your medical condition to help us assess your application. Thank you.