Personal Details Title*: —Please choose an option—MrMrsMissMsDrProfRevOther Other: Forename(s)*: Surname*: Gender*: MaleFemale Date of Birth (DD/MM/YYYY)*: Contact Details House Number/House Name*: Street Name*: Town/City*: County*: —Please choose an option—AvonBedfordshireBerkshireBordersBuckinghamshireCambridgeshireCentralCheshireClevelandClwydCornwallCounty AntrimCounty ArmaghCounty DownCounty FermanaghCounty LondonderryCounty TyroneCumbriaDerbyshireDevonDorsetDumfries and GallowayDurhamDyfedEast SussexEssexFifeGloucestershireGrampianGreater ManchesterGwentGwynedd CountyHampshireHerefordshireHertfordshireHighlands and IslandsHumbersideIsle of WightKentLancashireLeicestershireLincolnshireLothianMerseysideMid GlamorganNorfolkNorth YorkshireNorthamptonshireNorthumberlandNottinghamshireOxfordshirePowysRutlandShropshireSomersetSouth GlamorganSouth YorkshireStaffordshireStrathclydeSuffolkSurreyTaysideTyne and WearWarwickshireWest GlamorganWest MidlandsWest SussexWest YorkshireWiltshireWorcestershireOther 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. Reset Δ
