* Reasons for leaving current address?
* Has your client ever been evicted from any
accommodation? If yes, please state all
* List all addresses and periods of residence for the last 5 years and reason for move on’s as per example
Date of Registration at Local Authority:
Local Authority Registration Number:
* Appropriate contact person at Local Authority:
Is your client in receipt of a social welfare payment? If yes, please specify which entitlements:
* What else is your client eligible for?
Who was the perpetrator? Known or Unknown to her?:
Brief over view of what happened: i.e. physical violence/sexual violence/behavioural: please note this information is only to ensure that Daisyhouse can ensure the most appropriate support and care plan. i.e. ensure they are matched with the appropriate qualified professionals.
* General Practitioner Telephone Number:
Clients Need and Wants
What are the main three things you need from your time at Daisyhouse.
What are the main three things you want from your time at Daisyhouse.
If employed currently, or in the past, please give overview; type of work, length of employment etc:
If in training or education at present, please give details:
Please outline any education, training or employment goals your client may have and would like additional support to achieve:
Do you have any children? If yes, please outline their names, ages and care arrangements
Will this continue after move into Daisyhouse:
Data Protection Policy
Daisyhouse Housing Association fully respects your right to privacy, and will not collect any personal information without your consent. Any personal information provided will be treated with the highest standards of security and confidentiality, strictly in accordance with applicable data protection and other legislation. While the information provided will generally be treated as private within Daisyhouse and used only for the purpose of the services provided by Daisyhouse, it may be necessary from time to time for us to transfer your personal data on a confidential basis to other bodies to assist with your support needs and move on to long term accommodation (including, but not limited to, the Dublin Regional Homeless Executive, Dublin Co. Council, the County Council related to your own case needs, the Department of Social Protection, An Garda Síochána, the Health Service Executive, Tusla (CFA), social workers, medical practitioners or professional staff related to your care and welfare. We rely on you to provide us with accurate and complete information and to update us in relation to any change in the information provided.