Homelessness enquiry form

Complete this form to send us an initial enquiry.

Please use this form to explain your question or briefly describe your housing problem. If you are not sure and need help please contact a member of the team on one of the above telephone numbers during office hours.

	Name (1st Person) *
	Name ( 2nd person)
	Date of Birth (Person 1) *
	Date of Birth ( Person 2)
	Address
	Telephone Number *
	Number of Children
	Are you pregnant? *
	Do you have any of the following?
	Mental Health Problems *
	Alcohol Problems *
	Drug Problems *
	Convictions *
	Please give more details about the nature of your request for assistance.
	I confirm that the information provided is true and understand that this may be used to assess my housing circumstances. I also give authority to Amber Valley Housing to make enquiries regarding my approach for assistance. *

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