About You Housing Officer Email Address Why did you leave this address/become homeless? YOUR HOME Layout Current Housing Status Homeless At Home or Living with Parents Homeless At Home or Living with Parents Sofa Surfing Emergency Accommodation Council Tenant Private Rented Sector Temporary Accommodation Supported Accommodation Rough Sleeping Homemove Banding Band A Band A Band B Band C Not on Homemove If You Are Not Originally From Brighton and Hove, Where Did You Move From? ISSUES How did you become homeless & what is current your housing Issue? When did this roughly start? What have you done to get help and support so far? What has happened as a result ? Was your homelessness due to abuse, threats, violence or a hate crime? No Yes How would you rate Brighton and Hove City Council for the following How do you feel you have been treated by your housing officer? Have you ever been evicted from homelessness accommodation? if so what we're the reasons and what happened? How would Rate Your Current Homeless Accommodation and Landlord Do you feel in the accommodation you have been provided? Any Issues Or things you feel you want to raise whilst living there? Landlord Name Outcomes What would be a good outcome for you? if your journey is over were you happy with the outcome in the end? Rent Amount Per Week How much were you / are you spending on Electricity / Energy Each Week? Health, Wellbeing and Belonging
These questions are on a scale of 1= never, 2= not very often, 3= not often, 5= sometimes, 7= often, 8= very often, 9= most days, 10= all the time and so on. Please answer these honestly.
Loneliness: On a scale of 1 -10 in last two weeks how often have you felt loneliness? 1 2 3 4 5 6 7 8 9 10 Stress: On a scale of 1 -10 in last two weeks how often have you felt Stressed? 1 2 3 4 5 6 7 8 9 10 Suicidal Thoughts On a scale of 1 -10 in last two weeks how often have you felt suicidal or have suicidal thoughts? 1 2 3 4 5 6 7 8 9 10 Isolation: On a scale of 1 -10 in last two weeks how often have you felt you could not do or take part in activities? 1 2 3 4 5 6 7 8 9 10 Happiness: On a scale of 1 -10 in last two weeks how often have you felt happy? 1 2 3 4 5 6 7 8 9 10 Friendships & Family: On a scale of 1 -10 in last two weeks how often have you seen or spoken to friends and/or Family? 1 2 3 4 5 6 7 8 9 10 Do you feel your homelessness journey improved or worsened your mental health? Equality Layout Employment Status Employed Self Employed Student Not Working - Seeking Work Not Working - From a Disability In Education Write Your Gender Do You Have a Disability or Learning Impairment No Yes Not Sure First Select The Benefits You Get Sexual Orientation heterosexual LGBTQ+ Other Age Do You Have any children with a Disability or Learning Impairment No Yes Not Sure How does disability and impairment impact you and/or your family? Thank you for for completing this survey. I will keep you informed on the reports of these client surveys Additional comments or suggestions any interests to volunteer and help others
General Data Protection Regulations (GDPR) & Data Protection
Due to GDPR and Data Protection Legal Requirements around Authority and Consent Forms, Third parties, such as local councils require full written consent to comply with any advocacy casework requests.
The purpose of this form is to obtain:
written confirmation that you want a third party (Myself) to represent you during the investigation into your homeless related complaint / issue or Social Injustice; and
consent for me to share your personal information obtained during the investigation with relevant parities.
this can include but is not exclusive; Subject Access Requests on your behalf, the information will normally be sent to you, unless you state otherwise, these can also include statutory appeals & signposting.
Your right to withdraw consent: Please note that you have the right to withdraw either consent at any time; just let me know. By emailing [email protected] Do you need and agree for me to advocate on your behalf with a third party? *
This form should only be signed if you want the person named below ("your representative") to act for you in respect of your advocacy, complaint and/or social injustice issue.