Care Assessment

Personal Details

Title*: Other:
Forename(s)*: Surname*:
Gender*: MaleFemale Date of Birth (DD/MM/YYYY)*:
 

Contact Details

House Number/House Name*: Street Name*:
Town/City*: County*:
Postcode*: Contact Number*:
Other Telephone Number: Email Address*:
 

Self Assessment

The following sections of this Self Assessment will assist us in determining the correct level of support you may require to meet your needs. Please complete as many of the following questions as possible and use each text area if you wish to provide us with further information.

 
Meals
Do you require help preparing meals? YesNo
Laundry
Do you require help with laundry? YesNo
Washing/Bathing
Do you require help washing/bathing? YesNo
Clothing
Do you require help putting/taking off clothing? YesNo
Shaving
Do you require help shaving? YesNo
Using The Toliet
Do you require help using the toilet? YesNo
Cleaning
Do you require help cleaning the house? YesNo
Shopping/Groceries
Do you require help with your shopping? YesNo
Travelling
Do you require help travelling? YesNo
Finances
Do you require help with paying bills? YesNo
Benefits
Do you require help with benefits? YesNo
Housing
Do you require help with housing? YesNo
Gas/Electricity and Water
Do you require help with Gas, Electicity and Water? YesNo
Chiropody/Podiatry
Do you require help with Chiropody/Podiatry? YesNo
Dental Health
Do you require help with your dental/oral health? YesNo
Disability
Do you consider yourself disabled? YesNo
Mental Health
Do you have any mental health problems? YesNo
Mobility Indoors
Do you require help moving inside the house? YesNo
Mobility Outdoors
Do you require help moving outside of the house? YesNo
Medication
Do you require help with taking your medication? YesNo
Sight/Vision
Do you any difficulties with your sight? YesNo
Hearing
Do you have any difficulties with your hearing? YesNo
Talking/Speech
Do you have any difficulties with your speech? YesNo
Reading
Do you require help with reading? YesNo
Sleeping
Do you have any trouble sleeping at night? YesNo
Remembering/Memory
Do you have problems remembering things? YesNo
Safety/Security
Do you have any concerns about safety and security in
your home?
YesNo
Neighbourhood
Do you have any issues about neighbours, Anti Social
Behaviour, Parking, Bins etc?
YesNo
Driving
Do you require help with driving you car? YesNo
Companionship
Do you require someone to accomapny you to places like
shops, movies, church or pub?
YesNo
Residence
Where are you currently living? Own HomeFamily/FriendsCare/Residential HomeSupported Living/HousingOther
 
More Information
Do you have any medical or health issues? YesNo
Do you recieve help and assistance from family members
or friends?
YesNo
 

If there is anything further that you would like to tell to help us determine your needs, please tell us below.

 

Services Required

Home Care:Managed Live In Care:Respite Care:Learning Disabilities:Specialist Care:Companionship Care:Transition - Home From Hospital:Dementia and Alzheimer's Care:Extra Care - Supported Living:

 

Are you happy for us to contact you to discuss about your needs further?

YesNo
 

What Happens Next

A member of our Assessment team will review the information you have provided and get back to you to discuss your requirements further.