Lighthouse Application Form

Lighthouse Application Form

Please complete the form below to apply.
Applicant Contact Details
Full Name*

First NameLast Name
Current Address*

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Contact Number*
Email Address*
Date of Birth*

DayMonthYear
National Insurance No.*
Additional Contact Person
Full Name*

First NameLast Name
Current Address*

Street Address

Street Address Line 2

CityCounty

Postcode
Contact Number*
Email Address*
example@example.com
Relationship to applicant*
Family & Living Circumstances of Applicant
Marital Status*

SingleMarriedSeparatedDivorcedWidowed
Number of Children
Age(s) of Child(ren)
Accommodation*

SingleSpouseParentsFriendsOther
Are you currently on benefits?*

YesNo
If yes, please provide details
Health
How would you describe your personal health?*

ExcellentGoodFairPoor
Do you have any physical impairment, chronic disease or disability*

YesNo
If yes, please give details
Do you require assistance with daily activities as a result of any impairment?*

YesNo
If yes, please give details
Name of GP or last Doctor seen*
Address of GP or last Doctor seen*

Street Address

Street Address Line 2

CityCounty

Postcode
Contact number of GP or last Doctor seen*
Please list any prescribed medication you currently take
Substance Misuse
Do you use alcohol?*

YesNo
Do you use drugs?*

YesNo
If yes, do you inject?*

YesNo
What is your primary substance?
Do you require a medical detox?*

YesNo

About your usage

	Dosage	Frequency	How long have you been using this substance?
Alcohol
Heroin
Methadone
Subutex
Amphetamines
Cocaine/Crack
Ecstasy
Diazepam
Canabis
Legal highs
Other(s)

Are any of the above prescribed to you?

YesNo
If Yes, which ones?
Name of Prescriber
Address of Prescriber

Street Address

Street Address Line 2

CityCounty

Postcode
Email of Prescriber
example@example.com
Contact Number of Prescriber
Mental & Emotional Health
Have you ever experienced mental or emotional health problems?*

YesNo
Have you ever seen a psychiatrist?*

YesNo
Are you currently under psychiatric care?*

YesNo
If yes, please give details of your Community Psychiatric Nurse/Psychiatrist
Name of Psychiatric Nurse/Psychiatrist
Address of Psychiatric Nurse/Psychiatrist

Street Address

Street Address Line 2

CityCounty

Postcode
Email of Psychiatric Nurse/Psychiatrist
example@example.com
Contact Number of Psychiatric Nurse/Psychiatrist
Have you ever been in hospital as a result of mental or emotional health problems?*

YesNo
If yes, please provide details
Are you prescribed any medication for mental or emotional health issues?*

YesNo

If yes, please fill out the table

	Medicine	Dosage	Frequency	When did you start?
#1
#2
#3
#4

Have you ever had an eating disorder and/or have been know to self harm?*

YesNo
If yes, please provide details
Past Offences
Do you have a criminal record?*

YesNo
If yes, please provide details
Have you spent time in prison?*

YesNo
If yes, please provide details
Do you have any outstanding warrants*

YesNo
If yes, please provide details
Do you have any outstanding court appearances*

YesNo
If yes, please provide details
Have you ever been prosecuted for any violent offences?*

YesNo
If yes, please provide details
Have you ever been prosecuted for any sexual offences?*

YesNo
If yes, please provide details
Have you ever been prosecuted for arson?*

YesNo
If yes, please provide details
Are you subject to any statutory supervision or probation?*

YesNo
If yes, please give details of your Supervisor/Probation Officer
Name of Supervisor/Probation Officer*
Address of Supervisor/Probation Officer*

Street Address

Street Address Line 2

CityCounty

Postcode
Contact Number of Supervisor/Probation Officer*
Personal Statement
Please write in your own words why you want to come to The Lighthouse.*
Reference 1 of 2
Reference 1 - Name*

First NameLast Name
Reference 1 - Profession*
Reference 1 - Address*

Street Address

Street Address Line 2

CityCounty

Postcode
Reference 1 - Contact Number*
Reference 1 - Email
example@example.com
Reference 2 of 2
Reference 2 - Name*

First NameLast Name
Reference 2 - Profession*
Reference 2 - Address*

Street Address

Street Address Line 2

CityCounty

Postcode
Reference 2 - Contact Number*
Reference 2 - Email
example@example.com
Consent and Declaration
In order to make a decision about your admission to The Lighthouse it may be necessary to contact workers or agencies that have been involved with you. We will only contact people with your permission and any information received will be treated as confidential.

It should be remembered, however, that to process your application you must complete all the information requested on this form. The application process could be delayed if we are unable to liaise with other workers. To complete your application it may be necessary to share information given during your assessment with other relevant services.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
I give The Lighthouse permission to act on my behalf regarding my benefits and acquire any information concerning my history from my doctor throughout the duration of my programme.
I also give my consent for the staff from The Lighthouse to obtain written and/or verbal information about me from the following people for the purpose of assisting in my assessment.*

GPProbation OfficerPsychiatrist/CPNSocial WorkerDrugs Worker
I have completed this application form truthfully and to the best of my knowledge. I understand that any misleading information could jeopardise my entrance to The Lighthouse or remaining apart of the The Lighthouse.
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Lighthouse Application Form

Applicant Contact Details

Additional Contact Person

Family & Living Circumstances of Applicant

Health

Substance Misuse

Mental & Emotional Health

Past Offences

Personal Statement

Reference 1 of 2

Reference 2 of 2

Consent and Declaration