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.