If you have any queries about this form, or have any problems filling it in, please contact us on 01592 803280 or by email enquiries@dphsfife.org.uk. Please return your completed form to: Disabled Persons Housing Service (Fife) Caledonia House Pentland Park Saltire Centre Glenrothes KY6 2AQ
About you and your household
Mr / Mrs / Miss / Ms
First Name	Surname
Male	Female	Date of Birth	___/___/_____
N.I number
Address	Contact Information
Home
Mobile
Email
Postcode
What is the best way to contact you? (circle)	Phone	Letter	Email
If by phone, when is the best time?	AM	PM

Household Members – Only those moving with you
Name	Date of Birth	Relationship	Male/Female
___/___/_____
___/___/_____
___/___/_____
___/___/_____
___/___/_____

Do you require an interpreter?
No	Yes, what type:
Do you have any pets?
No	Yes, what pets:
Your current housing situation
Are you homeless, or threatened with homelessness?
No	Yes
What type of property do you live in?
House	Flat	Maisonette
Bungalow	Other
What floor do you live on? (If applicable)
Ground	First	Higher (please state)
How many bedrooms does your home have?
Who owns your property?
Fife Council	Housing Association	Owner Occupied
Privately Rented	Live with parent(s)	Live with friend(s)
Other (please state)
What disabilities do you or the household members moving with you have?
What makes your current property unsuitable for you?
Do you, or anyone moving with you use a wheelchair, do they:
Use a wheelchair:	Indoors	Outdoors
Does anyone have difficulties with:
External stairs	Internal stairs	Narrow doorways
Heating controls	Bathroom	Kitchen
Storage space	Socket height	Switch height

Your current housing situation cont.
Have you had any equipment supplied or adaptations made to your home?
If no, have you ever requested a Social Work Assessment? If so, when was this and what was the outcome?
Do you wish to remain in your own home?
No	Yes
Would you prefer to remain in your own home if it could be adapted?
No	Yes
Do you have an emergency call system?
No	Yes
If not, would you like information about getting one?
No	Yes

Accommodation required
Have you applied to the Fife Housing Register (FHR)? If so, what is your application number and current points?
FHR Number:	FHR Points
Have you applied for housing, or transfer, with any other housing providers? If so, which?
What areas would you like to live in?
Please tick if you would consider any area within Fife
If not, please note the top 3 areas within Fife you would be willing to consider.
1.
2.
3.

Accommodation required
Which type of housing would you prefer?
Council Housing	Housing Association	Private Let
Mid-Market Rent	Home Ownership	Shared Ownership
Shared Equity	Amenity Housing	Retirement/Sheltered Housing
What property type do you require? (mark E anything that is essential)
Level external access	Full wheelchair use internally	Barrier free internally
2 Storey (if accessible)	Ground Floor	Any suitable already adapted property
How many bedrooms do you require?
Please use this space to briefly tell us why you need more / less bedrooms. e.g. Under-occupying; additional family member; need a room for reasons of disability

Your household support needs
Please detail any support you current receive and from whom.
If you currently receive care/support – would you be interested in knowing about self-directed support?
No	Yes

Events and Newsletters
We regularly hold events and distribute our newsletter that may be of interest.
If you wish to be contacted about these, please indicate below if you would like to be added to our (e)mailing list.
Yes, add me to the mailing list	Initials:
We will contact you annually to see if you would still wish to remain on our mailing list.

Other Information
How did you hear about our service?
Family/Friend	Saw premises	DPHS Leaflet	Internet/Website
Hospital	Fife Council	Support Agency	Other, please state;
Please use the space below to add any other information you feel is relevant to your housing needs.

Customer Declaration
Please carefully read below and sign the form as we cannot process the form without your authorising signature/s.
The information you provide on this form will be processed with Disabled Persons Housing Service (Fife) in accordance with the General Data Protection Regulation (GDPR).
Disabled Persons Housing Service (Fife) will use this information for the purposes of providing you with independent housing information and advice, compiling anonymous statistical data. We may contact other agencies, such as housing providers and support agencies to obtain and share further information where required. By signing you agree to your information being used in this way and that all information supplied on our form is true.
If you are a *joint applicant, both signatures are required *partner/spouse
Applicant Signature:	Date:
Joint Applicant Signature:	Date:

External Auditing
I/We agree to the disclosure of my/our case file held by Disabled Persons Housing Service (Fife) “DPHS” to external auditors for the purpose of quality assurance and continuous improvement of the advice service provided by Disabled Persons Housing Service (Fife) “DPHS”.
If you are a *joint applicant, both signatures are required *partner/spouse
Applicant Signature:	Date:
Joint Applicant Signature:	Date:

Fife Housing Register Permission Form
By signing this form, I/we give permission to register and assess my Fife Housing Register (FHR) application form based on the information provided on the completed Disabled Persons Housing Service (Fife) registration form and any additional information gathered during a telephone conversation with Disabled Persons Housing Service (Fife).
If you are a *joint applicant, both signatures are required *partner/spouse
Applicant Signature:	Date:
Print Name:
Joint Applicant Signature:	Date:
Print Name:

Equal Opportunities Monitoring Form
Disabled Persons Housing Service (Fife) is committed to promoting equal opportunities and diversity in communities. We assist people in need regardless of sex, marital status, race, disability, age, sexual orientation, language, nationality, religious or political beliefs. To ensure we do not discriminate directly or indirectly we need to keep accurate records of all applicants. Please help us by completing this form. This information is for monitoring purposes only and will not affect your application. You do not have to provide this information if you do not want to.
Ethnic Origin
(please tick one box only for each person)
Self	1	2	3	4	5
(i)	White
(a) Scottish
(b) Other British
(c) Irish
(d) Gypsy/traveller
(e) Polish
(f) any other white background
(ii)	Mixed or multiple ethnic background
(iii)	Asian, Asian Scottish, Asian British
(a) Indian
(b) Pakistani
(c) Bangladeshi
(d) Chinese
(e) Any other Asian background
(iv)	Black, Black Scottish, Black British
(a) Caribbean
(b) African
(c) Any other black background
(v)	Other ethnic background
(a) Arab, Arab Scottish, Arab British
(b) any other group

Nationality
(please tick one box only for each person)
Self	1	2	3	4	5
UK National, resident in UK
European Economic Area (EEA) country
UK National returning from residence overseas
Any other country (please state)
Self	1
2	3
4	5
Religion – What is your religion?
(please tick one box only for each person)
Self	1	2	3	4	5
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Don’t have a religion
Prefer not to say
Other (please state below)
Sexual orientation- How would you describe the sexual orientation of each person?
Bisexual, Gay Man, Lesbian, Heterosexual (straight), Transgender, prefer not to say
Self	1
2	3
4	5