• 1Referrer details
• 2Service user details
• 3Medical and property details
• 4Assistance needed
• 5Summary

Progress

Referrer details

About you, the referrer

Have you gained the consent of the person you are referring?

Yes

No

Give reason why no consent has been sought

In what capacity are you making this referral?

E.g. relative, carer, advocate

First name

Last name

Email

Telephone

Who shall we contact if we need to do a telephone assessment?

Referrer (you)

The person you are referring

Someone else

First name

Last name

Telephone

Email

No information is required, please proceed to the next page.

Service user details

About the person you are referring

Title

e.g. Mr, Mrs, Dr

First name

Last name

Date of birth

Address

Postcode

Find Address

 Loading addresses...

Select Address -- Please select --

 

Address line 1

Address line 2 (optional)

City

Postcode

Clear postcode/address

Use the Lookup Postcode button to find the address.

If you cannot find the address, please enter it manually

Email (optional)

Phone

Gender

Female

Male

Other

Prefer not to say

Ethnicity -- Please Select -- Asian background Asian/Asian British - Bangladeshi Asian/Asian British - Indian Asian/Asian British - Pakistani Asian/Asian British - Any other Black background Black/Black British - African Black/Black British - Caribbean Black/Black British - Any other Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Mixed - Any other mixed background White - British White - Gypsy/Roma White - Irish White - Traveller of Irish Heritage White - Any other white background Any Other Ethnic Group Rather not say

Occasionally we use technology such as Skype and WhatsApp as part of the assessment process. Does the person you are referring or their family or friends have access to this technology?

Yes

No

Do they receive any of the following benefits?

Universal Credit

Housing Benefit

Guaranteed Pension Credit

Income Related Employment & Support Allowance

Income Support

Tax credits award notices where income is proven less than £15,050

None of the above

Do they currently receive any support from a social worker, physiotherapist, community occupational therapist, the incontinence service, or an NHS community occupational therapist?

Yes

No

Please state what help they currently receive

No information is required, please proceed to the next page.

Medical and property details

About their medical or health conditions

Provide details of any diagnosed medical conditions

Please do not use abbreviations

When was the diagnosis made?

What is the prognosis?

GP details (name and address of surgery)

NHS number

About their home

Is their property a

House

Flat

Other

Bungalow

Which floor is the flat located on?

Please specify (optional)

Is their property

Owner occupied

Housing association

Private landlord

Other

Please specify Housing Association -- Please Select -- Anchor Housing Group Cobalt Contour Eldonian English Churches Housing Group Guiness Partnership Jonny Johnson Housing Association North West Housing One Vision Onward Homes Pierhead Housing Plus Dane Progress Care Regenda Riverside Sanctuary South Liverpool Housing Steve Biko Torus Your Housing Other

Please give name, address and contact details of landlord

Please give details

Do they live

Alone

With family

With carers

Are they hoping to move?

Yes

No

Please state why they want to move

No information is required, please proceed to the next page.

Assistance needed

What do they need help with?

Tell us they you need help with

Stairs

Bathing

Access to property

Toileting

Kitchen tasks

Bed or chair tasks

Stairs

You told us they need help with their stairs. Can you tell us what this difficulty is?

Do they have any of the following? -- Please Select -- One Handrail Two handrails A stairlift None

Bathing

You told us they need help accessing their shower/bathing facilities. Can you tell us what the difficulty is?

Does their bathroom have

Bath

Walk in shower

Bath with shower

Separate shower

Do they use any of the following?

Bath lift

Shower board

Shower chair

Wheeled shower chair

Drop down shower chair

Shower stool

Swivel bather

None

Please specify

Access to property

You told us they need help accessing their property. Can you tell us what this difficulty is?

How do they currently access the property?

Independently

With assistance

They are housebound

Do they use any aids such as a walking stick or grab rail to enter and exit the property?

Yes

No

Please tell us what aids they use

Not known

Steplift

Ramp

Half step

With Handrails

With Grab rails

Mobility aid

Toileting

You told us they need help with toileting. Can you tell us what this difficulty is?

Do they use any equipment or rails to assist them getting on and off your toilet?

Yes

No

Please select which aids they use

Raised toilet seat

Toilet frame

Commode/shower chair over toilet

Drop down rails

Grabrails

Wash/dry toilet

Other

Please specify

Bowel

Bladder

Both

Kitchen tasks

You told us they need help with kitchen tasks. Can you tell us what the difficulty is?

Can they carry hot drinks and meals safely from their kitchen area?

Yes

No

Please tell us more (optional)

Bed or chair tasks

Do they need help getting in and out of a chair?

Yes

No

Can you tell us what the difficulty is?

What type of chair seat do they use?

Settee

Armchair

Reclining chair

Riser chair

High back chair

Dining chair

Other

Please specify

Do they use any equipment to help get out of bed?

Yes

No

Please specify

Bed lever

Hoist

Mattress variator

Profiling bed

Not known

Additional information

If you would like to include any other information, please tell us (optional)

No information is required, please proceed to the next page.

Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page

 Loading form summary...