Llys Ton Application Form

Guidance Notes for Initial Application Form This form is for you to tell us about your needs and will help us to decide whether you qualify for Extra Care housing. Please check that you meet these criteria; You should normally be aged 50 or over. You should have a need for housing related support; such as support with letters, activities or contacts. You should have a need for help with personal care on a regular basis. You will need to request a ‘Social Services and Well-Being Wales Assessment’ to identify your personal needs. Contact the Common Access Point on 01656 642279 or contactassessmentreviewteam@bridgend.gov.uk If you have any queries or require this form in another format, please contact V2C staff at Llys Ton on 01656 745666.

Step 1 of 19

What is your current place of residence?

An Owner occupier

In Private rented accommodation

In Housing Association/ Social housing tenancy

Other

If you selected "Housing Association / Social Housing", please specify the landlord:

If you selected "Other", please state your housing type:

Applicant Details

Applicant Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of birth

National Insurance Number

Telephone number

Joint Applicant Details (Please only complete this section if you are applying with a joint applicant. If you are the sole applicant, you may skip this section.)

Joint Applicant Name

First Last

Joint Applicant Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Joint Applicant Date of birth

Joint Applicant National Insurance Number

Joint Applicant Telephone number

Details of the person completing form if not the applicant: (Only complete if you are not the applicant)

Name of person completing form if not the applicant:

First Last

Telephone number

Relationship to applicant

Do you need help with any of the following?

Do you need help getting in and out of the shower?

Do you currently receive help with getting in and out of the shower?

Who helps you to get in and out of the shower?