CHAP - Partner Details Form

Partner Details Form

This form is required for users of the Live Chat Service if requested by an advocate, so that we can obtain more information about your background. Once you have completed the form, please click on the Submit button at the bottom of the page and your form will be e-mailed directly to us. You will require an e-mail client to be installed on your computer, or alternatively, you can print off the form and post it to us (see contact us for address information). Click the submit button once only and then return to the home page.

Name:
Address:
Date of Birth:
NI Number:
E-Mail Address:
How did you hear about CHAP?
Your Status (Please select one)	Single Couple One Parent Family Unit Widowed Divorced or Separated
Other family members being rehoused (age / gender)
How many adults (16+) in the house are..... (Please tick appropriate boxes)	Unemployed Self employed Employed (P/T) Employed (F/T) Student/Trainee Sick Leave
Are any members of your household in receipt of benefits?	Yes No
If you have ticked yes to the above question, what benefits are they?
Have any members of your household just been released from prison or on remand?	Yes No
Do any members of your household have health issues?	Yes No
If yes to the above question please fill in the appropriate details	Physical Health Yes No
	Issue / Medication Taken
	Mental Health Yes No
	Issue / Medication Taken


	Drug Problem Yes No
	Issue / Treatment


	Alcohol Problem Yes No
	Issue / Treatment



What is your current acccommodation?	Local Authority Housing Association Private Let Temporary Furnished Hostel Owner / Occupier Sleeping Rough Family / Friends Other

	(If other....please specify)


Are you involved with any other agencies at present	Addiction Agency G.P. Hospital Homeless Team Social Work Criminal Justice

What is your housing problem?