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This application form is intended for completion by or on behalf of an applicant with a disability. Where the application is for two or more people sharing, each person should complete a separate form.

Information provided on this form will be treated as confidential and will not be disclosed without your permission.

Once you have completed the form please click the SEND button at the foot of the page and this will forward the application to us. We will contact you as soon as possible following recept of your application.

If you would rather print out an application and fill it in you can download the forms on the application forms page.

Part 1 General

Title: First Name: Surname

Date of Birth:

Address for Correspondence:

Postcode:

Telephone: Email:

Is there anyone you wish to share with? Yes No

Name	Relationship	Additional Information if Relevant

Would you be willing to share with another person wih disabilities? Yes No

Part 2 Household

If the applicant is living somewhere other than the correspondence address in part one please state where, otherwise leave blank:

Present Address:

Is your present accommodation accessible? Yes No

Details of your home:
Type of home: If Flat, Which Floor? If other, please give details:

Is there a lift? Yes No

Are you confined to the house? Yes No

If yes, state why:

Is there any problem with the accommodation or circumstances at your present home? Yes No

If yes, state why:

Have you applied for housing or a transfer with any other housing authority or agency? Yes No

If yes, state which one:

What are your reasons for applying to Freespace?

Part 3 Disability

What disability/disabilities do you have?

Please give details of any special equipment which you use?

Can you do the following? (Please select as appropriate)

Can you...

Walk?	Yes A Little With Aid No
Use a Wheelchair?	Yes A Little With Aid No
Prepare Snacks?	Yes A Little With Aid No
Prepare Meals?	Yes A Little With Aid No
Feed Yourself?	Yes A Little With Aid No
Do your own shopping?	Yes A Little With Aid No
Manage Buses/Go to town?	Yes A Little With Aid No
Get about the house?	Yes A Little With Aid No
Get out of a chair?	Yes A Little With Aid No
Get into/out of bed?	Yes A Little With Aid No
Manage medicines?	Yes A Little With Aid No
Clean the house?	Yes A Little With Aid No
Do the garden?	Yes A Little With Aid No
Do the Laundry?	Yes A Little With Aid No
Get dressed?	Yes A Little With Aid No
Use the bathroom?	Yes A Little With Aid No
Have a bath?	Yes A Little With Aid No
Have a shower?	Yes A Little With Aid No
Have an overall wash?	Yes A Little With Aid No
Switch lights on/off?	Yes A Little With Aid No
Open/close doors?	Yes A Little With Aid No
Answer the Telephone?	Yes A Little With Aid No
Drive a vehicle?	Yes A Little With Aid No

Part 4 Medical and Personal Details

Do you have any of the following? Please check as appropriate
A district nurse?
A health visitor?
A Home Help?
An occupational therapist?
A Volunteer?
Any other regular help?

We would like your permission to contact one of the above about your application?
Please give details about the most appropriate person. (Name, address and job title/role)

Please give the name and address of your doctor(G.P.)
(We will not contact him/her without your permission)

Do we have your permission to contact him/her about your application Yes No

Is there any other medical information you wish to add?

Do you have any objections to information provided in this form being passed on to housing agencies?
Yes No

Declaration

I declare that the information provided in this form is correct and wish to apply to Freespace for personal care and support
Tick here to confirm

Date:

"I have my own support and can make my own choices"

"The fact that it gives me freedom of choice and independence"

"Because it frees up my parents to live their lives"

"Complete flexibility and complete control over my own life and the power to hire my own staff."

"...I live independently and in control of my own life. All my needs are provided for with excellent customer service."

"(Freespace) allows me to live independently in my new home"

"Makes me feel settled and secure"

"No other provider offers the care and support I need on such a flexible basis 24/7 every day of the year."

"Because there are not many places like Freespace that allows for independence"

"The Freespace ethos suits my needs and lifestyle perfectly"

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