Name:

Date of birth:

Age:

Address line 1:

Address line 2:

Town/city:

Postcode:

Contact Tel. No:

Nationality: UK EU Other Not Known

Religion: C of E Christian Muslim Catholic Buddhist Sikh Other Not Known

Sex: Male Female

Marital Status: married single seperated widowed divorced living with partner

How many children do you have?:

What are their ages?:

Name and address of next of kin:

Relationship to you:

Do you have any legal actions outstanding?:

Details of last conviction/sentence:

Details of previous convictions:

Details of Probation Orders:

Name of Probation Officer:

Address of Probation Officer: (line 1)

Address of Probation Officer: (line 2)

Address of Probation Officer: (town/city)

Address of Probation Officer: (postcode)

Have you been in rehabilitation before?: yes no

If 'yes' please enter where and when:

Which project are you applying for?: Kenward House or Boons Park Kenward Barn Highgate Hall Malthouse (2nd stage) Final Stages (3rd stage) Don't know

What do you hope to achieve during your stay?:

Has there been any problems arising from: Drugs or alcohol Violent behaviour Excessive gambling None

If your problem is alcohol, would you describe yourself as: An alcoholic A heavy drinker A hard drinker

A problem drinker None

If your problem is drugs (or drugs & alcohol), are you: An addict A casual user None

Have you ever suffered from: Hepatitis Epilespsy T.B. Schizophrenia

H.I.V. Breakdown Loss of memory Depression None

Are you presently taking medication?: yes no

If yes, what do you take?:

Have you had or are you having any psychiatric treatment?: yes no

If yes, give details of where, when & what for:

Name of Doctor:

Address of doctor: (line 1)

Address of doctor: (line 2)

Address of doctor: (town/city)

Address of doctor: (postcode)

May we approach him/her for further details?: yes no

Education:

What work do you prefer?:

Name and address of referral agency:

Telephone number:

Date vacancy required:

Have you been formally assessed as needing residential care?: yes no

Date of assessment:

By whom (name & address):

Have Social Services agreed to fund your stay?: yes no

Which Social Services:

Other Comments:

Please now enter the date of your application:

Please tick this box to give us permission to approach funding authorities, your medical practitioner and probation officer, on your behalf, if necessary

Email address: (optional)