Able Community Care

Please complete the questionnaire giving details of the person requiring the services of a housekeeper/carer. Only the basic questions on the two centre pages need to be completed unless there are two people living at the same address who both require this service - in which case please give details of the second person on the last page. We apologise for the fact that this is a lengthy questionnaire, but our very considerable past experience has shown how important it is to be thorough.

The Agency is registered under The Data Protection Act 1998. The Agency always endeavours to get a good ‘match’ between clients and housekeeper/carers - our experience shows that the detailed information we obtain from this questionnaire is invaluable for this purpose.

Please ensure that full Postal Codes are given with all addresses and STD Codes with telephone numbers. Under ‘date of birth’ please give day/month/year. If there are any questions about which you feel uncertain, please give us a call during the day or leave a message after office hours and someone will contact you to try to help.

Question: What do I do now?

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Post or fax the form back to Able Community Care at our address given above.

Question: What happens next?

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You will be contacted by telephone to arrange a mutually convenient ‘Assessment of Needs Visit’. This can take place in the person’s home, a nursing home or in a hospital.

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An Offer Letter will be posted or faxed to you by mid-day on the following working day. (Unusual circumstances may mean that the Offer Letter cannot be sent out so quickly). The Offer Letter will contain the quotation for the total weekly costs.

Question: How much does the above assessment of needs and quotation cost?

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This part of the service is free of charge and totally without obligation - to all persons residing in England, Scotland, Wales and The Channel Islands.

Question : What happens next?

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We need you to indicate to us that the terms in the Offer Letter are acceptable and that you wish to go ahead. Once we have sent the Offer Letter you will not be approached again.

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Assuming that you wish to proceed, a named Care Manager from our office will contact you to arrange when the service is to begin.

PLEASE COMPLETE THIS FORM IN BLOCK LETTERS

Surname ___________________________________ Title ________ Date of birth _____/_____/_____
Forenames _________________________________ Nationality _______________________________
Address ____________________________________________________________________________
___________________________________________________________ Post Code _______________
Tel. No. ________________________ Fax _________________ E mail _______________________

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

Name ____________________________________ Relationship ________________________________
Tel. No. _____________________________
Please give the name, address and telephone number of your Doctor.
Name ________________________________ Address ________________________________________
______________________________________________ Tel. No. ___________________________

CORRESPONDENCE: We confirm all bookings in writing. Should correspondence be sent to: The CLIENT, a REPRESENTATIVE of the client, or BOTH ?

(Please delete the options which are not appropriate)

If correspondence has to be sent to a Representative, please give the following details:
Surname and Title ______________________________________________ Initials _____________
Status _____________________________ (ie. whether a relation, solicitor, bank manager etc.)
Address _____________________________________________________________________________
______________________ Post Code _______________ Tel. No. ____________________________
Fax ___________________________ E mail ______________________________

PAYMENT OF ACCOUNTS
To whom should the Agency’s accounts be sent? Please enter details below.
(Simply write ‘C’ if client, or ‘R’ if Representative given above. For anyone else, please enter full details.)

Surname ________________________________________ Title ____________ Initials ____________
Status _____________________________ Address ___________________________________________
______________________ Post Code _______________ Tel. No____________________________

Fax ___________________________ E mail ______________________________

Date of Commencement of Care (for office use only) .............................................................



HOUSEKEEPER/CARER INFORMATION
Smoking.

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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?     yes / no

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If this is not feasible, would you be prepared to accept a person who does, provided that they limit this to their own accomodation?                         yes / no

Drivers. Please note: We cannnot always guarantee to provide carers who are car owner/ drivers,
but we will make every effort to do so if required.

STATE OF HEALTH OF CLIENT

Please give full details of any health problem eg. incontinence, confusion, senility, paralysis, deafness, poor sight, stroke after care, any named disease - Parkinson’s Disease, M.S., Menieres Disease, Alzheimer’s Disease, Motor Neurone Disease, etc. and also details of any special dietary requirements.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Weight ______________    Height ________________    Is help required during the night?    yes / no
If YES, please indicate the frequency:    Times per night __________  Times per week __________

Do you use:  A commode?    yes / no          A Zimmer frame or any other walking aid?   yes / no

                      A wheelchair?   yes / no

Do you:         Require lifting?  yes / no          Partial  /  Total lifting?  (please ring appropriate answer)
                      Have a hoist?    yes / no          If yes, please give details:
Name of Manufacturer ______________________________ Model ______________________________
Date of last maintenance check _______________________
Do you:        Require help with washing, bathing, dressing?     yes / no
If yes, please give details: __________________________________________________
Do you:        Attend a Day Centre?     yes / no

ACCOMMODATION DETAILS

Type of residence (house, bungalow, flat?) __________________________________________________
Amenities: Type of heating________________________________
Washing Mashine?     yes / no               Drier?     yes / no               Freezer?     yes / no
Refrigerator?              yes / no               Type of cooker:     Gas / Electric / Microwave
Location of home: urban / rural Distance from shops ________________________________
Are bus or train services available? (Please give details) ________________________________________
_____________________________________________________________________________________
Are there any pets?     yes / no   (Please give details) _________________________________________
Are there any other domestic staff?     yes / no
What accommodation is available for the housekeeper/carer?  (Please give details) ___________________
_____________________________________________________________________________________
Please give details of anyone else who resides in the household __________________________________

_____________________________________________________________________________________

GENERAL INFORMATION
The Agency makes every effort to obtain a ‘good match’ between clients and housekeeper/carers 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:

_____________________________________________________________________________________
_____________________________________________________________________________________

EXPECTED DURATION

How long do you anticipate you might require the services of a housekeeper/carer?
Up to 3 months?     yes / no               3 months or longer?     yes / no

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 CLIENT

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Weight ______________    Height ________________    Is help required during the night?    yes / no
If YES, please indicate the frequency:    Times per night __________  Times per week __________

Do you use:  A commode?    yes / no          A Zimmer frame or any other walking aid?   yes / no

                      A wheelchair?   yes / no

Do you:         Require lifting?  yes / no          Partial  /  Total lifting?  (please ring appropriate answer)
                      Have a hoist?    yes / no          If yes, please give details:
Name of Manufacturer ______________________________ Model ______________________________
Date of last maintenance check _______________________
Do you:        Require help with washing, bathing, dressing?     yes / no
If yes, please give details: __________________________________________________
Do you:        Attend a Day Centre?     yes / no

GENERAL INFORMATION

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

_____________________________________________________________________________________
_____________________________________________________________________________________

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

_____________________________________________________________________________________

Able Communmity Care

It would be helpful to us if you would tell us how you came to hear of Able Community Care. If it was through a doctor, solicitor, social worker, an existing client, or you obtained our details from a Local Authority Approved or Accredited List we would also be pleased to know.

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Thank you for your co-operation in completing this form.