Liverpool City Council

About you

Title e.g. Mr, Mrs, Dr

If other, please state

First name

Last name

Date of birth

Address

Postcode

Use the Lookup Postcode button to find the address.

If you cannot find the address, please enter it manually

Do you have an email address?

Yes
No

Telephone

Gender

Female
Male
Other
Prefer not to say

Ethnicity

Please specify

Occasionally we use technology such as Skype and WhatsApp as part of the assessment process. Do you or your family or friends have access to this technology?

Yes
No

Select which of the following benefits you receive

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 you 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 you currently receive

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

Medical or health conditions

Provide details of any diagnosed medical conditions, do not use abbreviations

When was the diagnosis made?

What is the prognosis?

GP details (name and address of surgery)

NHS number - optional

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

What do you need help with?

Tell us what you need help with

Stairs
Bathing
Access to property
Toileting
Kitchen tasks
Bed or chair tasks - such as transferring in or out of bed or a chair
Other

Please specify the other help you need

Stairs

You told us you need help with your stairs. Can you tell us what your difficulty is?

Do you have any of the following stair aids?

Who provided the stairlift, and how long have you had it?

Access to property

You told us you need help accessing your property. Can you tell us what your difficulty is?

How do you currently access the property?

Independently
With assistance
I am housebound

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

Yes
No

Please describe your aids or difficulties entering and exiting the property e.g. grab rails, walking sticks, other adaptions

Toileting

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

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

Yes
No

Please select which aids you use

Raised toilet seat
Toilet frame
Commode/shower chair over toilet
Drop down rails
Grab rails
Wash/dry toilet
Other

Please state

Kitchen tasks

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

Can you carry hot drinks/meals safely from the kitchen?

Yes
No

Please tell us more

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.

Occupational Therapy Request - Service User