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Pilsdon was founded in 1958 as a community of people who
endeavour to live together as one household according to the precepts of the
Christian Gospels, offering shelter, hospitality and spiritual refreshment for
those in need of refuge without regard to gender, race or creed.
There is a daily pattern of prayers (optional), meals, work and recreation.
Everyone is expected to assist to the best of their ability with any work
required. It is a dry house and the consumption of alcohol or illicit drugs on
or off the premises is not allowed. Pilsdon is not a detoxification or treatment
centre and does not accept people on methadone or similar prescriptions.
There is a referral process, this form being the first stage. We aim to make
Pilsdon a safe place for those who live here. We do not accept people who have a
history of, or convictions for sexual abuse, arson or non-drug /alcohol related
violence.
Information that you give on this form will be treated as confidential unless it
is clearly necessary to share it to protect your health or safety or the health
and safety of others.
Please print the form below, complete it and return
it to:
Pilsdon Manor
Bridport
Dorset
DT6 5NZ
APPLICATION FORM
Name & current address.
Date of birth: Telephone Numbers (inc mobile):
Home address if different from above
Why do you want to come to Pilsdon? How do feel that coming to Pilsdon will help
you?
What are you able to offer to the life of the Community at Pilsdon?
Do you have any concerns about your health at present?
What is the name and address of your GP?
Are you seeing any specialists? Please give details.
Do you have a social worker, probation officer, community nurse or other
professional help at present? If so please give details
Have you had any serious illnesses in the past? Please give details
Do you have any allergies or special dietary requirements?
Have you had a problem with drugs or alcohol? If you have please give details
Do you require a detox before coming?
If you have a record of criminal offences, please tell us about them.
Are you receiving any benefits? Are you eligible to receive housing benefit?
What is your current accommodation? (e.g. rented/living with family/homeowner
etc.)
Who is your next of kin? Please give details of names and addresses:
Please place a tick to tell us your ethnic background and religion. (This
information helps us to ensure that we are not acting discriminatively and to
provide the appropriate support).
Ethnic background
White British Irish Other
Mixed White & Black Caribbean White & Black African White & Asian Other
Asian or Asian British Indian Pakistani Bangladeshi Other
Black or Black British Caribbean African Other
Chinese or other ethnic Chinese Other
Refused
Religion Buddhist Christian Muslim Sikh Jewish Hindu Other
..
Signed_______________________________________________ Date_____________
IT IS VERY IMPORTANT THAT YOU FILL IN BOTH CONSENT FORMS BELOW, SIGNING EACH.
CONSENT FOR RELEASE OF INFORMATION
I consent to the relevant personal information being given to the Pilsdon
Community by the persons/organisation named below, for the purpose of my
application to that community, on the understanding that any information
released to Pilsdon will be treated as confidential.
Signed
.. Date
..
Your Name and Address (please print)
..
..
Names and Address of your Doctor
.
..
..
Name and Address of another professional person who knows you (e.g. Social
Worker, Probation Office, Community Psychiatric Nurse etc.)
.
..
..
CONSENT FOR RELEASE OF INFORMATION
I consent to the relevant personal information being given to the Pilsdon
Community by the persons/organisation named below, for the purpose of my
application to that community, on the understanding that any information
released to Pilsdon will be treated as confidential.
Signed
.. Date
..
Your Name and Address (please print)
..
..
Names and Address of your Doctor
.
..
..
Name and Address of another professional person who knows you (e.g. Social
Worker, Probation Office, Community Psychiatric Nurse etc.)
.
..
..
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