HFIL Needs Assessment

• Document No.

• Audit Title

• Name of prospective tenant

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Prospective tenant details

• Title

  Mr

  Mrs

  Miss

  Ms

• Name

• Address

• Telephone number

• Mobile number

• Email Address

• Known as

• Is this for a joint tenancy?

  Yes

  No

• Name of second tenant

• Contact details (if different to the above)

• Address of prospective property

• Date tenancy to commence

  Date

• National Insurance number

• Date of birth

  Date

• Place of birth

• Have you ever held a Medway Council tenancy before?

  Yes

  No

• Address

• Check rent account

• Has prospective tenant had previous rent arrears?

  Yes

  No

• Are you currently a tenant of any other LA or Housing Association?

  Yes

  No

• What is your tenancy reference?

• Do you have a car?

  Yes

  No

• Registration number

• Do you have a mobility scooter/buggy?

  Yes

  No

• Do you have any pets?

  Yes

  No

• Provide details

Next of kin or close contact

• Name

• Relationship to you

• Address

• Telephone number

• Mobile number

• Has this person given permission for us to contact them?

  Yes

  No

• Is this person willing to be a key holder?

  Yes

  No

• Would you like to add another next of kin or close contact?

  Yes

  No

• Name

• Relationship to you

• Address

• Telephone number

• Mobile number

• Has this person given permission for us to contact them?

  Yes

  No

• Is this person willing to be a key holder?

  Yes

  No

Services

• GP Name

• Address and number

• Brief medial history

• Do you use care agencies to support you?

  Yes

  No

• Agency name

• Care manager name

• Phone number

Current health

• Have you had any falls recently?

  Yes

  No

• Could medical conditions cause a medical emergency?

  Yes

  No

• Please give details

• Do you receive any care or support in relation to your medical conditions?

  Yes

  No

• Please give details

• Are you currently taking any prescribed medication?

  Yes

  No

• Please list prescribed medication

• Do you use alcohol?

  Yes

  No

• How much do you drink?

• Do you use illegal drugs?

  Yes

  No

• Please give details

• Have you ever had help with an alcohol or drug problem?

  Yes

  No

• Have you ever been suspected/convicted of a criminal offence?

  Yes

  No

• What was it for and how long ago?

• Do you currently have a probation officer?

  Yes

  No

• Have you ever been violent to other people?

  Yes

  No

• Have you ever caused harm to yourself?

  Yes

  No

• Have you ever served in the Armed Forces?

  Yes

  No

Setting up home

• Would you require any help with setting up a new home? e.g. benefits advice, adaptations, Social Services, help with furnishings

  Yes

  No

• Details

Homes for independent living

• What expectations do you have about living in the scheme?

• Scheme living has been explained?

  Yes

  No

• Persons not on Housing Benefit will have to meet the full cost of the Support Charge. For persons on full or partial Housing Benefit, the Support Charge will be met by the Supporting People Grant. The Support Charge is to cover the cost of services provided by the Scheme Manager and is part of the tenancy agreement.

• Has the supporting people service and charge been explained?

  Yes

  No

• The Scheme Manager will be onsite each day to carry out a 'buzz round'.
  
  However, there may be times when the Scheme Manager will be away from the scheme due to covering other schemes, annual leave, attending training courses or meetings. There is a 24 hour Lifeline system in place in the event of an emergency.

Support service

• Do you understand the Support Service and what it involves? (Tenancy related support, form filling, facilitating etc)

  Yes

  No

• Do you have any hobbies?

  Yes

  No

• Would you like help in pursuing your hobby?

  Yes

  No

• Details

Cultural and faith needs

• Medway Council houses many difference people in terms of religion, colour, race and sexual orientation. Every tenant has equal rights and responsibilities.
  
  Please answer the following questions so that Medway Council can provide you with information on appropriate services should you wish.

• Ethnicity

  Select White British White Irish White other Mixed white and black Caribbean Mixed white and black African Mixed white and 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 Gypsy or traveller Chinese Other Not stated

  • White British
  • White Irish
  • White other
  • Mixed white and black Caribbean
  • Mixed white and black African
  • Mixed white and 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
  • Gypsy or traveller
  • Chinese
  • Other
  • Not stated

• Religion

  Select Christian Buddhist Hindu Jewish Muslim Sikh No religion Prefer not to say

  • Christian
  • Buddhist
  • Hindu
  • Jewish
  • Muslim
  • Sikh
  • No religion
  • Prefer not to say

• Sexual orientation

  Select Bi-sexual (both sex) Hterosexual (straight) Gay (man) Gay women (lesbian) Other Prefer not to say

  • Bi-sexual (both sex)
  • Hterosexual (straight)
  • Gay (man)
  • Gay women (lesbian)
  • Other
  • Prefer not to say

• Medway Council has an Equal Opportunities Statement. If you would like a copy of this statement then please request one.

Mobility

• Do you use aids such as walking stick, crutch, zimmer frame, gutter frame or wheeled trolley?

  Yes

  No

• Comments/support needed

• Do you have a wheelchair and/or scooter?

  Yes

  No

• Comments/support needed

• Can you use a lift?

  Yes

  No

• Comments/support needed

Living skills

• Do you do your own preparation and cooking of meals?

  Yes

  No

• Comments/support needed

• Do you do your own shopping?

  Yes

  No

• Comments/support needed

• Do you do your own housework and laundry?

  Yes

  No

• Comments/support needed

• Do you need help with getting washed, bathed, getting dressed or getting up in the morning or going to bed at night?

  Yes

  No

• Comments/support needed

Sensory

• Do you have any problems with hearing?

  Yes

  No

• Comments/support needed

• Do you have a visual impairment?

  Yes

  No

• Is this corrected with glasses?

  Yes

  No

• Comments/support needed

• Are you registered blind or partially sighted?

  Yes

  No

• Comments/support needed

• Do you suffer from a speech impairment?

  Yes

  No

• Comments/support needed

• How would you best describe your memory?

  No concerns

  Occasionally forgetful

  Poor short term memory

  Disorientated in time and place

• Comments/support needed

Finances

• Do you manage your own finances?

  Yes

  No

• Comments/support needed

• Do you understand about rent and regular bill payments?

  Yes

  No

• Comments/support needed

• Do you need help with form filling and/or correspondence?

  Yes

  No

• Comments/support needed

Risk Assessment

• Drug/alcohol dependency

  Yes

  No

• Risk rating

  High

  Medium

  Low

• Comments

• Financial

  Yes

  No

• Risk rating

  High

  Medium

  Low

• Comments

• Mobility

  Yes

  No

• Risk rating

  High

  Medium

  Low

• Comments

• Sensory

  Yes

  No

• Risk rating

  High

  Medium

  Low

• Comments

• Living skills

  Yes

  No

• Risk rating

  High

  Medium

  Low

• Comments

• Mental health

  Yes

  No

• Risk rating

  High

  Medium

  Low

• Comments

• Cultural and faith

  Yes

  No

• Risk rating

  High

  Medium

  Low

• Comments

• Social isolation

  Yes

  No

• Risk rating

  High

  Medium

  Low

• Comments

• Suitability for building

  Yes

  No

• Risk rating

  High

  Medium

  Low

• Comments

• Any future support needs identified?

• Scheme Manager to check with Adult Services (x4466) re any previous history. Please note any details.

Identification

• Take pictures and confirm which 2 forms of ID have been provided.

• Photos of ID

  Media

• Applicant one

  Select Passport Driving licence Birth certificate DWP letter Bank or building society statement Housing benefit letter Council tax letter Utility bill Medical card Bus pass

  • Passport
  • Driving licence
  • Birth certificate
  • DWP letter
  • Bank or building society statement
  • Housing benefit letter
  • Council tax letter
  • Utility bill
  • Medical card
  • Bus pass

• Applicant two

  Select Passport Driving licence Birth certificate DWP letter Bank or building society statement Housing benefit letter Council tax letter Utility bill Medical card Bus pass

  • Passport
  • Driving licence
  • Birth certificate
  • DWP letter
  • Bank or building society statement
  • Housing benefit letter
  • Council tax letter
  • Utility bill
  • Medical card
  • Bus pass

Tenancy check

• Name of landlord

• Date reference request letter sent

  Date

• Date reference received

  Date

Agreement

• Do you agree with this assessment?

  Yes

  No

• Applicant 1 signature

  Sign

• Applicant 2 signature

  Sign

• Interviewing officer signature

  Sign

Property

• Has the property been offered?

  Yes

  No

• Has property been accepted?

  Yes

  No

• Reason property refused

• Rent is payable weekly from the tenancy start date. Two weeks rent is required in advance at sign up. The weekly rent is: