Housing Options Mobility Assessment Referral Form Assessment details Do you have an active Housing Options application with a known Housing Options reference number? Required Yes No Please provide your housing options reference number: Required Do you require a Housing Options mobility assessment to determine if you are eligible for mobility points? Required Yes No Please tell us why you require a housing options mobility assessment: Required Have you had a Housing Options mobility assessment within the last 12 months? Required Yes No Please do not continue to complete this form. If you have previously been assessed and would like to request a review of the decision, you need to do this within 21 days of receiving the decision. This is explained within your decision letter. Please use the following link to contact the Housing Options team to Request a formal review Details of person requiring a Housing Options mobility assessment Title: Required Please select Mr Mrs Miss Mx First name: Required Last name: Required Date of birth: Required Format DD/MM/YYYY Current address: Required Postcode Lookup Enter address including postcode: Required Contact number: Required Contact Person's Full Name (if different from above): Email address: Required Current Accommodation (Property type/ tenure): Required Reason requiring rehousing: Required Please provide a brief description of your mobility difficulties and whether you use any mobility aids in and around the home: Required Do you have any other equipment or adaptations that you utilise in and around the home: Required Please include details of any relevant courses of treatment courses or surgery that you have undergone in the last 6 months or are awaiting and of the healthcare professionals or specialists who have been treating you: Required Please attach any supporting documents to support your need for a Housing Options Mobility Assessment due to mobility difficulties: Drop files here or click to upload Choose a file… You do not have a requirement to continue to complete this form. Return to homepage Please contact the Housing Options Team and submit a Housing Options application form
