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Please read this guidance before you fill in this form
You should complete this form if you are on the Housing Register or have applied to be on the Housing Register AND you or someone permanently living with you has a medical need to be rehoused.

We will not consider your application unless there is evidence that an applicant’s current housing situation is having a direct impact on their and/or a household member’s medical condition. The term ‘medical grounds’ also covers disability.

A medical assessment is only intended to show how the medical condition is affected by the current housing situation and how it might be improved by living somewhere else.

Please answer all of our questions and provide extra information where possible. You must explain fully the difficulties you and/or your family are experiencing and how your present accommodation affects your ability to carry out every day living activities in your home. Please fill in all sections of the form. If you do not, we will return the form to you, as we will not be able to make a full assessment.

You must sign the declaration and consent page so that we may contact health professionals directly.

Do not fill this form in if:
You have an illness or injury that is likely to get better with treatment, for example if you are recovering from surgery.
Your housing issues are solely due to:
• over-crowding or under-occupying
• state of disrepair in your current home for example, damp, condensation
• anti-social behaviour or neighbour problems
• a notice to quit being served
• a relationship breakdown

Supporting Evidence - Please note: We need supporting evidence of your medical condition.

There are different types of health record. Accessing them is free, and healthcare professionals have a legal requirement to allow you to see them. How to access your health records - NHS (www.nhs.uk)
Please see examples of supporting evidence we accept.

GP records
Appointment Letters
Care Plan
Consultant’s Letters
Discharge Summary
Referral Letters
Summary Care Record Occupational Therapist Report
Diagnoses, Reports and Results
Social Worker's Full contact details

Qualifying Questions

Are you including supporting evidence with this form?
If you tick No then we will not consider you for rehousing on medical grounds.
Is your medical condition caused by overcrowding?

You can find information about overcrowding by looking at 'Bedroom Standards' in the Tenants' Handbook section of our website: www.dacorum.gov.uk/tenantshandbook

Is your medical condition affecting your everyday life and likely to last more than 12 months?
If you tick No then we will not consider you for rehousing on medical grounds.
Is your medical condition a result of poor conditions within your current home?
(This could include mould, damp or small living spaces)

About You and Your household

Your details

Address details not found, please select 'Enter Address'.

Is the person in Household seeking medical assessment different than listed?

Person in Household seeking medical assessment

Address details not found, please select 'Enter Address'.

Your living situation

Please tick any applicable:

Other people living permanently with you

Do you drive and have the use of a car?
Does any member of your household drive and have the use of a car?
Do you have access to a driveway or allocated parking space?
Does the applicant receive any benefits in relation to Medical/Health/Disabilities?

Which component(s) and what rate do they receive?

Please provide evidence of your benefits with this assessment.

Personal Independence Payment (PIP)
Employment and Support Allowance (ESA)
Disability Living allowance (DLA)
Universal Credit
Severe disablement Allowance
Carers Allowance
Attendance Allowance
Industrial Injuries Benefit

Your current accommodation

Layout of your current home: (Please tick all that apply)
What does your current home have? (Please tick all that apply)
Do you use any medical equipment, daily living equipment or Telecare in the home?

Medical Information

Medication and Treatment

You will need to provide evidence of your GP records, Summary Care Record and prescriptions.

Please select which type of care or support you receive

Please give details of any recent hospital treatment you have received for your disability or health problem(s).

Support contacts

Please give details of all the medical professionals and support workers involved in treating the conditions described in this form. This includes your GP and other doctors, Occupational Therapists, Social Workers, Community Psychiatric Nurses, Consultants and specialists.

Address Details not found.

Mobility difficulties

Do you have a wheelchair?
Do you have a power assisted chair?
Do you have mobility difficulties that require you to use a walking aid such as a walking frame or stick?
Are you requesting an extra bedroom because of your health needs or disability, in addition to the bedrooms that you are entitled to in the Allocation Policy?
For information on bedroom entitlement please click https://www.dacorum.gov.uk/docs/default-source/housing/bedroom-standards.pdf
Please tell us if you have any difficulty with any of the following:
Please tell us how you are able to carry out the following activities
What is your expectation following completing this form?
(Tick all that apply, as it is not always possible to have properties adapted.)

Supporting Evidence

Please upload all relevant evidence for your application.


I agree that I will notify Dacorum Borough Council of any changes in my circumstances that affect the details I have given on the form. The information I have given on this form is true and correct to the best of my knowledge. I understand that knowingly making false statements could give the council grounds for cancelling or amending my housing application, or for prosecuting me. I also understand that I could lose any tenancy granted as a result of deliberately giving false information. I understand and agree that this form and any additional supporting documentation that I submit can be sent to an independent medical advisor/company to be assessed. Any assessment completed is based solely on written information provided.

I give permission for council staff to contact other agencies for information relevant to assessing my housing and medical need, and for those agencies to supply information to the council. I understand that you may use and store any information I have given on this form and that this may be seen by any housing association or agency that offers homes to people on the housing needs register.

For further information, see the council’s website (Data Protection Statement) or contact the Data Protection Officer or Audit Manager at The Forum, Hemel Hempstead. Dacorum Borough Council has a duty to protect the public funds it administers so may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes.