Service User Application Form Live-In Care

Service User Application Form Live In Care

All fields are required marked *. 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.

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

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Step 2 of 5

All fields are required marked *. Please give details only if 'Yes' is selected for questions below. Please provide full details of any health problem, any named disease, and special dietary requirements.

Weight:

Times per night:

Times per week:

Partial or total lifting:

Name of manufacturer:

Model:

Date of last maintenance check:

Details:

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Step 3 of 5

All fields are required marked *. Drivers: Please note, we cannot always guarantee to provide carers who are car owner/drivers but we will make every effort to do so if required. Please provide accommodation details below.

Type of residence (house, bungalow, flat?)*

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

If yes, please give details:

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

If yes, please give details:

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

What accommodation is available for the housekeeper/carer?*

Please give details of anyone else who resides in the household, if no one else please put None:*

Smoking:

Some of our clients have a preference for non-smokers. Would you prefer a non-smoker?* —Please choose an option—Select optionYesNo

If not feasible, would you accept a person who smokes but limits this to their own accommodation?* —Please choose an option—Select optionYesNo

General Information: Please give details of interests, hobbies, previous occupation, and religion if any:*

Expected Duration: How long do you anticipate requiring the services of a Carer?* —Please choose an option—Select optionUp to 3 months3 months or longer

If there are any children under sixteen years old living in the home or who may visit, please give details or reply none:*

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Step 4 of 5

All fields are required marked *. Please specify correspondence preferences and emergency contacts.

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

Relationship:*

Tel. No.:*

Email (optional):

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

Address:*

Tel. No.:*

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Step 5 of 5

All fields are required marked *. Please specify payment details.

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

If it is not the client or Representative from Step 3

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

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

Surname:

Title:

Date of birth:

Forenames:

State of Health of Additional Client:

Details:

Weight:

Height:

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

If yes, times per night:

If yes, times per week:

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

Do you use a Zimmer frame or 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

If yes, partial or total lifting:

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

If yes, name of manufacturer:

If yes, model:

If yes, date of last maintenance check:

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

If yes, details:

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

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

How did you hear about Able Community Care?*

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