Online Application / Referral Form

Help A Squaddie Application for Assistance

If there is an emergency situation please dial 999.

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

Step 1 of 5

20%

Are You(Required)

The Applicant

The Referral agency

Other

Referrer Details and reason for referral(Required)

About the applicant

Full name(Required)

First Last

Have you ever been known by any other name(Required)

Yes

Previous Name

First Last

Date of birth(Required)

DD slash MM slash YYYY

Gender(Required)

Male

Female

Non-Binary

Prefer not to say

Address(Required)

Street Address Address Line 2 City Postcode

Contact Number(Required)

Email Address(Required)

National insurance number(Required)

Service history

Service Number(Required)

Date of enlistment(Required)

DD slash MM slash YYYY

Date of discharge(Required)

DD slash MM slash YYYY

Regiment of service(Required)

Do you have proof of service(Required)

Yes

Maybe

When can you provide proof of service?(Required)

Now, via file upload now

Within 48 hours by email

I cannot provide proof of service

Please upload you proof of service(Required)

Accepted file types: jpg, png, pdf, Max. file size: 128 MB.

Please email your proof of service to us at kerry@helpasquaddie.org.uk.

Medical history

GP name and address(Required)

GP telephone number(Required)

Medical History(Required)

Please list all current diagnosed medical conditions

Medications(Required)

Please list all current medications

How would you rate your physical and mental health?

Physical Health(Required)

Very Good

Good

Satisfactory

Poor

Very Poor

Mental Health(Required)

Very Good

Good

Satisfactory

Poor

Very Poor

Additional details

Please give details including name, date of birth, gender of children/partner/friend to be included in the referral.(Required)

Emergency Contact(Required)

Please provide: Relationship/Name/Phone No

Is support provided by any of the following?(Required)

Family Member

Friend

Social Worker

CPN

Other support worker

Other military charity

No support

Please provide their details(Required)

Housing History for the past 5 years including dates(Required)

Are You applying for a room in the Russell Aston Home For Veterans(Required)

Yes

Do you agree to follow the strict rules listed below:
1. No smoking is allowed anywhere inside the property.
2. No Alcohol is allowed to be consumed inside or outside the premises which includes restaurants and public houses.
3. No drugs or drug paraphernalia is allowed anywhere on the premises including the outside spaces.
4. All visitors to the property must be signed in, and are the responsibility of their host.
5. No overnight guests are allowed, all visitors must remain in the communal areas at all times. Visitors are not allowed in any of the bedrooms.
6. All visitors must leave by 21.30 hours and be signed out by their host.
7. No more than 2 visitors at a time.
8. All residents are to clean up after themselves in the communal areas.
9. No excessive noise is allowed at any time. Please do not cause a noise nuisance to other residents or neighbours.
10. Aggressive, threatening or violent behaviour towards staff or other residents will not be tolerated. Racist, homophobic sexist or any other discriminatory comments will also not be tolerated.
11. Anyone found to have stolen goods on the premises may be asked to leave and the Police may be informed. This includes theft of other resident’s property or Help A Squaddie property.
12. No offensive weapons are allowed on the premises including the outside spaces. This includes keeping knives from the kitchen on your person or in your bed space.
13. All residents’ privacy must be respected – do not enter another resident’s bed space without permission.
14. Heating must be kept at a reasonable level.
15. The rubbish must be put out for collection regularly.
16. No services may be installed in the property without permission from Help A Squaddie.
17. All medication must be kept securely in your room at all times.
18. Residents must be appropriately dressed in communal areas.
19. No sleeping on the sofa/chairs in communal areas overnight.
20. Do not wedge open Fire doors.

I agree to the above terms(Required)

Yes

As part of the application process for a room at The Russell Aston Home for veterans, you will be required to undergo alcohol and drug testing and must provide a clear (Negative) result before entering the property. Do you agree to this requirement.(Required)

Yes

Have you previously lived in supported accommodation?(Required)

Yes

Who provided this support?(Required)

Do you have any criminal convictions?(Required)

Yes

Details of any convictions(Required)

(Nature of Offence/Sentence/Dates) - In accordance with Rehabilitation of Offenders Act 1974

Is it safe to visit you in your home?(Required)

Yes

Have you ever been refused support?(Required)

Yes

In which area is support required?(Required)

Debt problems

Access to training/employment

Homelessness

Filling in forms/making phone calls

Finding suitable accommodation

Maintaining accommodation

Mental Health problems

Health and wellbeing

Problems with alcohol

Problems with drugs

Social isolation

Access to veterans foodbank

Other

If other please state here:(Required)

Declarations

Declaration of accuracy(Required)

I hereby confirm that the information provided in this document is accurate and complete to the best of my knowledge, and includes all relevant details necessary for the proper assessment of this referral. I understand that should any information be found to be false, misleading, or intentionally omitted, support may be refused and/or my placement at The Russell Aston Home For Veterans may be terminated.

I agree

I disagree

Data Protection(Required)

Under the General Data Protection Regulations Act it is a requirement to obtain your consent to share information about you with other agencies and organisations who may be involved in providing services to you. You have a right to prevent this and therefore do not have to consent if you do not want your information to be shared. However, it may be difficult to provide you with some of the services you need if you do not give your consent. You can revoke your permission at anytime by informing us in writing of this decision. I give my permission for agencies to obtain further information from all other relevant agencies. I understand that this information will only be made available to all providers/organisations that are able to assist me to obtain the correct level of support.

I agree

I disagree

Documents needed with Application for financial support are:
1. Three (3) months Bank Statements
2. Proof of Benefits

Can you supply these?(Required)

Yes

N/A

Date of Application(Required)

DD slash MM slash YYYY

Untitled

First Choice

Second Choice

Third Choice

Untitled

Name

First Last