Get Help

If you have a disability, you’re over 55 years old, or if you are a member of the Armed Forces community, we’re here to help you find the right home, in the right place. To get help, fill in this form.

The information you provide in this form will help us to explore all the housing options open to you.

You will be contacted within six weeks by one of our expert Housing Options Brokers, with information that is tailored to you.

Alternative format

Do you require this form in a different format? If so, please get in touch using the button below.

Your personal data

We keep your data safe, secure and confidential. We only use it to explore your housing options and will only share it if we have your consent.

Once your case is concluded or if we have not heard from you for six months we will destroy all the information you have given us.

1Your Details

2Your Current House

3Your Need To Move

4Your Income

5Home Energy Scotland

Are you filling in this form for someone else? *

Name *

First

Last

Date of birth *//

Required unless a telephone number is supplied

Phone

Required unless an email address is supplied

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name of Local Authority

How did you hear about us?

Preferred method of contact *

Call
Email
Post

Tell us a little about your current housing situation and why it is unsuitable for you *

e.g. size, access, location. 200 Word Limit

If you consider yourself to have a disability is it:

Physical
Mental
Learning
Other

If other please specify here:

Are there any concerns about your / their legal capacity? *

A concern may be if the person is unable to act or make decisions, communicate decisions, understand decisions or remember decisions.

Are you, or a member of your household, in the armed forces or a veteran? *

Are you currently homeless or threatened with homelessness? *

Do you own, rent or have another arrangement? *

How large is your mortgage?

Who is the lender?

Roughly how much is still due to pay off?

How much do you think your home is worth?

If other please specify here:

Please describe your current house *

Would you prefer to remain in your home if it could be adapted? *

Do you want to move? *

In which area do you want to live? *

Would someone be living with you? *

Yes
No
Unsure

If you answered yes, who would be living with you?

First

Last

Date of birth//

Relationship

e.g. spouse, brother

Additional household members? (2) *

Add another household member below

First

Last

Date of birth//

Relationship

e.g. spouse, brother

Add another household member? (3) *

Add another household member below

First

Last

Date of birth //

Relationship

e.g. spouse, brother

Add another household member? (4) *

Add another household member below

First

Last

Date of birth//

Relationship

e.g. spouse, brother

Add another household member? (5) *

Add another household member below

First

Last

Date of birth//

Relationship

e.g. spouse, brother

Add another household member? (6) *

Add another household member below

First

Last

Date of birth//

Relationship

e.g. spouse, brother

Add another household member? (7) *

Add another household member below

First

Last

Date of birth//

Relationship

e.g. spouse, brother

Do you have any pets? *

If yes please specify below

How many bedrooms do you need and what features should the house have?

Have you registered your housing needs with the Council? *

Name of Council *

Reference Number

Have you registered your housing needs with any Housing Associations or Co-operatives? *

Please list the name of the housing association and reference number of each application *

What other steps have you taken to find a suitable home?

What is your household's income from benefits?

Telling us your household income allows us to determine exactly which options you are able to afford

Universal Credit

Per week
Per month

Child Tax Credits

Per week
Per month

Carers Allowance

Per week
Per month

Income Support

Per week
Per month

Incapacity Benefit

Per week
Per month

Employment Support Allowance (Contribution-based [ES(C)]

Per week
Per month

Employment Support Allowance (Income-related [ES(IR)])

Per week
Per month

Pension Credit (Guarantee element)

Per week
Per month

Disability Living Allowance (DLA - Care Component)

Per week
Per month

Disability Living Allowance (DLA - Mobility Component)

Per week
Per month

Severe Disablement Allowance

Per week
Per month

Personal Independence Payments (PIP - Daily living component)

Per week
Per month

Personal Independence Payments (PIP - Mobility component)

Per week
Per month

Housing Benefit

Per week
Per month

Other

Per week
Per month

Give details

What is your household's monthly income from employment?

Per week
Per month

Is this sum received before or after tax & other deductions?

Before
After

How much do you have in savings, endowments, or any sums of money available or due to you in the near future?

How much IN TOTAL do you owe in debts, loans, rent or mortgage arrears, credit cards etc?

Is any of this debt secured against your property?

Have you ever been bankrupt?

How much, if anything, could friends or family contribute to assist you financially to buy?

Would another family member or friend, consider buying a property to let to you if you could repay them with rent through Housing Benefit?

Home Energy Scotland is a Scottish Government programme run by the Energy Saving Trust. They offer free impartial advice on making your home warmer and cheaper to heat.

Do you find your home hard to heat? *

Yes
No
Prefer not to say

Home Energy Scotland Permission *

Do you provide your permission to be contacted by Home Energy Scotland and for information about the outcomes of this referral to be shared with Housing Options Scotland up to one year after the date of referral? If you have previously been in contact with Home Energy Scotland, that information and any outcomes in the current year will be shared. Home Energy Scotland will keep the data for auditing purposes and in case they need to contact you or your third party in future to assess customer satisfaction.

Do you worry about fuel bills? *

Yes
No
Prefer not to say