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.
Summary Care Record Occupational Therapist Report
Diagnoses, Reports and Results
Social Worker's Full contact details