Supported Living Application Form What you need to do now

Supported Living Application Form
Please attach a
regular sized
photograph of
yourself to this
form
To complete this form, you should seek input from people that know you
well. You could ask your parents, sisters & brothers, friends, key worker,
social worker & local service manager.
Please make sure the form is fully completed. Further information may need
to be gathered following this application form.
What you need to do now...
(1)
Apply for a place on the local housing list
 Apply to Galway City Council if you wish to live in the city or Galway
County Council if you wish to live outside the city.
 When you are applying, you can put the name of the Supported Living
Coordinator (Denise Higgins) on the form as the “co-respondent” so
that the council will notify Ability West of the status of your housing
application.
 Indicate that you would consider housing support via the RAS (Rental
Accommodation Scheme)
(2)
Apply for Rent Supplement
 Department of Social Protection's representative (formerly known as
the Community Welfare Officer) or local Citizens Information Service
can help you fill in this form
(3)
Talk to your family, Keyworker, day service and any other key
people about Supported Living
Supported Living is...A safe and decent home of your own,
choice, personalised assistance, support from others who care
about and respect you’ (John O’Brien)
About you
What is your name?
What is your address?
What is your phone number?
What is your date of birth?
Where do you live now?
Support
Do you have someone in your family
(or a friend) who can support you
with the process of moving to your
own home?
If yes what is their name?
What is their address?
What is their phone number?
Who is your Keyworker?
What is their contact number?
Yes
No
More about you
What school/training courses have
you completed?
Do you have a Person Centred Plan?
(PCP)
Your Home
Who do you live with now?
Family
Friend(s)
Alone
Other
residents
Someone else
- Who?
What kind of place do you live in at the moment?
Family
Home
Own
Apartment
Hostel
Group Home
Somewhere
else. Where?
If you're living with someone else,
what would they think about you
moving into your own home?
Have you ever lived alone?
If yes, did you have any support?
Yes
No
Yes
No
If you had support, what was the
support required for?
Have you ever lived in a group home
or hostel?
Yes
No
Yes
No
If yes, which one?
If you have lived in a group home
when was this?
How soon could you move in to your
own home?
Does it matter what floor your
apartment is on if you moved in to an
apartment building?
If yes, please tell us what you need and
why.
What area would you like to live in?
(the city, county, near home, please state as
many options as you wish)
About your day
What do you do during the day?
What do you do in the evenings and in
your spare time?
Your Health
Do you have a disability?
Yes
No
Yes
No
Do you take medication?
Yes
No
If yes, do you need support with your
medication?
Yes
No
Yes
No
If yes please tell us about it
Do you have a health problem?
If yes please tell us about it
If you do need support – what do you
need?
If yes who?
Do you have any issues with your
mental health?
If yes please tell us about it
More questions about you
If you are angry or sad what do you
do?
If you move to your own home will
you be able to stay in touch with your
family & friends?
Yes
No
If yes, how will you stay in touch?
Cooking and eating
Can you make yourself a hot drink
(like tea or coffee)?
Yes
No
Can you make snacks
(like sandwiches, sausages, beans on
toast, or tinned soup)?
Yes
No
Yes
No
If yes, what snacks do you often
make?
Can you make meals using meat and
vegetables?
If yes, what do you often cook?
How many times in a week do you
cook for yourself?
If you don’t cook where do you get
your meals?
Looking after yourself and
your home
Can you do housework?
(washing up, hoovering, cleaning)
Yes
No
Can you budget for the things you
need like bills and food?
Yes
No
Have you had problems with money
before and have you got into debt?
Yes
No
If you get Disability Allowance, do you
manage it yourself?
Yes
No
Do you have a Laser card?
Yes
No
Yes
No
If yes, what jobs do you often do?
How do you wash your clothes?
Do you need any assistance with personal care?
(such as showering, dressing)
Money
Do you have support to set up
standing orders & direct debits to pay
your rent and bills?
If yes – who will help you with this?
What assistance will you require with
budgeting?
What support do you need?
Can you do shopping on your own for
clothes and/or food?
Yes
No
Yes
No
On your own
With friends
If no, who helps you?
Can you use a mobile phone?
Do you use the buses or trains?
If someone leaves you a note can you
read it?
Yes
No
With help
Is there anything you think you need to learn to do better?
Shopping
Cooking
Cleaning
Budgeting
Something
else – what?
Tell us why you want to move into your own place
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Living in your own place?
Living in your own place can be good. Sometimes it can be difficult as well.
Have you thought seriously about what it would be like?
What do you think the good things
might be?
What do you think the bad things
might be?
Would you like to live on your own
or
Share your home with a friend or
housemate or a family member?
To live in your own home, you will need to:
 be willing to act as a good neighbour / housemate
 pay your rent & bills on time
 look after your home
 engage with volunteers & support staff (when you require them)
 keep in touch with family & friends
Would you be willing to do all of
these things?
Yes
No
Please read the next part, make sure you understand it, then sign your
name;
I understand that I might not be able to get my own place straight away
because:

a lot of people are ahead of me on the housing list or
 my support team might decide it wouldn't be right for me or
 it may take time to get supports organised
I understand that I can only be supported to move to my own home if I am
willing to let volunteers, support workers, friends and family support me.
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 I hereby accept and understand that Ability West will hold personal
information which is necessary for the purposes of the Supported
Living Application only, as provided for in the Data Protection Acts
1988 and 2003 and Freedom of Information Act 1997.
 I agree that my contact details can be used for these purposes.

I have read and understood this declaration.
Signed ……………………………………………………………………..
Date
……………………………………………………………………..
Now you’ve finished...
Thank you for taking the time to complete this form
Well done 
Please note that this application form does not guarantee a Supported Living service
Return to the Supported Living Coordinator, Ability West, Blackrock House, Galway
Supported Living Application – Prepared by Kieran Keon, Social Worker © Ability West