1Referrer details 2Medical and property details 3Assistance needed 4Summary Progress Referrer details About you Title e.g. Mr, Mrs, Dr If other, please state 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 Do you have an email address? Yes No Email Telephone Gender Female Male Other Prefer not to say Ethnicity -- Please Select -- Asian/Asian British - Bangladeshi Asian/Asian British - Indian Asian/Asian British - Pakistani Asian/Asian British - Any other 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 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 and property details 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) About your home Is your property a House Bungalow Flat Other Which floor is your flat located on? Please specify (optional) Is your property Owner occupied Housing association Private landlord Other Please specify Housing Association -- Please Select -- Anchor Housing Group Torus Steve Biko South Liverpool Housing Sanctuary Riverside Regenda Progress Care Plus Dane Your Housing Pierhead Housing One Vision North West Housing Jonny Johnson Housing Association Guiness Partnership English Churches Housing Group Eldonian Contour Cobalt Onward Homes Other Please give name, address and contact details of landlord Please give details Do you live With family With carers Alone Are you hoping to move? Yes No Please state why you want to move No information is required, please proceed to the next page. Assistance needed 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? -- Please Select -- One handrail Two handrails A stairlift None Who provided the stairlift, and how long have you had it? Bathing You told us you need help accessing your shower/bathing facilities. Can you tell us what the difficulty is? Does your bathroom have Bath Walk in shower Bath with shower Separate shower Bathing equipment None Bath lift Shower board Shower chair Wheeled shower chair Drop down shower chair Shower stool Swivel bather Other Please specify other 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 Bed or chair tasks Do you 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 you use? Settee Armchair Reclining chair Riser chair High back chair Dining chair Other Do you use any equipment to help get out of bed? Yes No Please select the type of equipment you use 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...