Service User Application

Form For Home From Hospital Support

Service User Application Form Home From Hospital Support

Important Details About This SERVICE USER APPLICATION FORM HOME FROM HOSPITAL SUPPORT

Please complete giving details of the person requiring our service. You are under no obligation and will not incur expense until such time as you agree to commence with our services after detailed discussion with us.

Your Data

To process your application, we need to record and store your details on our secure database. If this basic level of permission is not granted, then we will not be able to continue with this application.

Please confirm below that you give Able Community Care Ltd permission to store your details.* —Please choose an option—Select optionI doI do not

Able Community Care Ltd promises never to share or sell your information to other organisations or businesses and you can opt out of our communications at any time by phoning 01603 764567, writing to Able Community Care, The Old Parish Rooms, Whitlingham Lane, Trowse, Norwich, NR14 8TZ or by sending an email to info@ablecommunitycare.com.

Your information will be kept for 1 year after the end of registration unless you ask us to remove it from our records. After this time, the information we keep about you will be minimised and archived.

If you would like to read our full Privacy Statement, please request a copy by contacting us as above.

Prospective Client

Surname*

Title*

Forenames*

First Language*

Address*

Post Code*

Tel. No.*

E mail*

Reason for Hospital Admission

Please give full details of any health problem, any named disease and also details of any special dietary requirements.*

Health Problems, Diseases & Dietary Requirements*

Weight*

Height*

Is help required during the night?* —Please choose an option—Select optionYesNo

Do you use a commode?* —Please choose an option—Select optionYesNo

Do you use a Zimmer frame or any other walking aid?* —Please choose an option—Select optionYesNo

Do you use a wheelchair?* —Please choose an option—Select optionYesNo

Do you require lifting?* —Please choose an option—Select optionYesNo

Do you have a hoist?* —Please choose an option—Select optionYesNo

Do you require help with washing, bathing, dressing?* —Please choose an option—Select optionYesNo

Do you attend a Day Centre?* —Please choose an option—Select optionYesNo

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Service User Application Form Home From Hospital Support

Step 2 of 5

Please complete all fields with a *.

Carer Information

Drivers: Please note: We cannot always guarantee to provide carers who are car owners/drivers but we will make every effort to do so if required.

Accommodation Details

Type of residence*

Amenities: Type of heating*

Washing Machine?* —Please choose an option—Select optionYesNo

Drier?* —Please choose an option—Select optionYesNo

Freezer?* —Please choose an option—Select optionYesNo

Refrigerator?* —Please choose an option—Select optionYesNo

Type of cooker* —Please choose an option—Select optionGasElectricMicrowave

Location of home* —Please choose an option—Select optionUrbanRural

Distance from shops*

Are bus or train services available?* —Please choose an option—Select optionYesNo

Are there any pets?* —Please choose an option—Select optionYesNo

Are there any other domestic staff?* —Please choose an option—Select optionYesNo

What accommodation is available for the carer?*

Please give details of anyone else who resides in the household*

Smoking

Some of our clients have a preference for non-smokers and we make every effort to comply with their wishes. Would you prefer a non-smoker?*

—Please choose an option—Select optionYesNo

General Information

The Agency makes every effort to obtain a ‘good match’ between clients and holiday companions and, in order to assist us in this, it will be helpful if you can give us details of interests, hobbies, your previous occupation and your religion if any or NONE:

Details

Expected Duration

How long do you anticipate you might require the services of a Carer?*

If there are any children under sixteen years old living in the home or who may visit, please give details*

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Service User Application Form Home From Hospital Support

Step 3 of 5

Please complete all fields with a *.

Correspondence

Correspondence: We confirm all bookings in writing or by email. Should correspondence be sent to:* —Please choose an option—Select optionThe CLIENTA REPRESENTATIVE of the clientBOTH

If correspondence is to be sent to a Representative, please provide details:

Surname and Title:

Initials:

Status (e.g., relation, solicitor, bank manager):

Address:

Post Code:

Tel. No.:

Email:

Emergency Contacts

Please give the name and telephone number of any person who should be contacted in an emergency.*

Name*

Relationship*

Tel. No.*

E mail

Your Doctor

Please give the name, address and telephone number of your Doctor.*

Name*

Address*

Tel. No.*

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Service User Application Form Home From Hospital Support

Step 4 of 5

Please complete all fields with a *.

Payment of Accounts

To whom should the Agency’s accounts be sent?*

If it is not the client or Representative from Step 4

If 'Other', please provide details:

Surname and Title:

Initials:

Status (e.g., relation, solicitor, bank manager):

Address:

Post Code:

Tel. No.:

Email:

Would you prefer to receive our correspondence by email?* —Please choose an option—Select optionYesNo

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Service User Application Form Home From Hospital Support

Step 5 of 5

Complete this section only if there is another person in the household who requires care

Is there another person in the household who requires care?* —Please choose an option—Select optionYesNo

General Information: Please assist by giving details of interests, hobbies, previous occupation, and your religion:*

General Information

It will be helpful if you can give us details of interests, hobbies, your previous occupation and your religion if any or NONE:

Details

It would be helpful to us if you would tell us how you came to hear of Able Community Care. Please provide details:*

Details*

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