Access this service yourself If you think Revival's trusted team could help or support you, fill out the form below and someone will be in touch! Full name * Date of birth * Home address * GP details * Please provide the name of your GP and the address of the surgery Telephone number * I give my permission for Revival to use my details to support my application * Yes No Customer accommodation What kind of accommodation are you currently living in? * Living with family Hostel Council tenant Living with friends Private rented tenant Housing association tenant Shared housing Homeowner Other Customer ethnicity What is your ethnic group? * White Mixed or multiple ethnic groups Asian or Asian British Black, African, Caribbean or Black British Other ethnic group Prefer not to say Do you have any current physical or acute health concerns, mobility issues, sensory impairments, or communication issues we should know about? * Yes No If you answered yes, please tell us more Do you have any current or previous mental wellbeing issues that may affect your mood or behaviour? * These could include any memory concerns, capacity, or a Dementia diagnosis. Yes No If you answered yes, please tell us more Do you have any current financial concerns? * This could be outstanding debt, struggling to pay rent, or having accounts in arrears. Yes No If you answered yes, please tell us more Do you have a history of drug or alcohol abuse? * This could be any current issues with alcohol or any other substances related to you or your home. Yes No If you answered yes, please tell us more Are you at any harm from others? * This could be any current or previous incidents of domestic abuse, harassment, or threats from family, a partner, or associate. Yes No Prefer not to say If you answered yes, please tell us more Are there any hazards we need to know about before entering your property? * For example are there any pets kept there? Yes No If you answered yes, please tell us more Please tell us why you'd like to be referred to this service? *
