YMCA York and East Riding - Housing Application

Who are you?*

I am the applicant
I am referring someone

Information of applicant in need of housing support

Full name*

Date of birth*

Referral type*

Self-referring
Referring agency

Place of birth

Contact number

Email

Gender*

Ethnicity

Please specify*

National Insurance number*

Additional information

Are you rough sleeping (street homeless/sleeping outside)?

Yes
No

Refugee
AS

Your referral source

Please specify*

Support needs

Reason for Application

0 of 200 max characters

Please specify any specific support needs (e.g. mental health, drugs/alcohol, disabilities etc.)

Are you pregnant?

Yes
No

What is your main source of income?

Please state

Do you have any previous criminal convictions?

Yes
No

Please speficy*

Arson
Sex offences
Other

Please speficy*

Support agencies

Are you receiving any support from any agencies (e.g. Social Services, drug/alcohol services/probation/mental health services etc.)?*

Yes
No

Agency name*

Contact number*

Key/emergency contact details

Name

Relationship

Address

Contact number

Email

What to bring to your interview

You will be asked to provide your past 5 years of previous addresses. Please bring along to your interview:

Proof of income
Two documents as proof of ID
Proof of National Insurance (NI) number
Home office documents (if applicable)

Name

This field is for validation purposes and should be left unchanged.