Service User Access Form - Able Community Care

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Online Service User Access Form

Important Details About This 'SERVICE USER ACCESS FORM'

Please complete the questionnaire below giving details of the person requiring the services of a housekeeper/carer. 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 happens next?

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.
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?

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?

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

THE CLIENT

Title

Forenames

Surname

Date of birth

Address

Postcode

Tel. No.

Fax

Email

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

Name

Relationship

Tel. No.

Email

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

Name

Address

Tel. No.

Email (if known)

CORRESPONDENCE: We confirm all bookings in writing.

Should correspondence be sent to

	The client
	A representative of the client
	Both client and representative

If correspondence has to be sent to a Representative, please give the following details

Title

Forename

Surname

Status

Address

Postcode

Tel. No.

Fax

Email

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

Title

Forename

Surname

Status

Address

Postcode

Tel. No.

Fax

Email

HOUSEKEEPER/CARER INFORMATION

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?

	Yes
	No

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 cannot 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 e.g. spinal injury, acquired head injury, 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 so, please indicate number of times per night help is required

Or indicate number of times per week help is required at night

Do you use a commode?

	Yes
	No

Do you use a wheelchair?

	Yes
	No

Do you use a Zimmer frame or any other walking aid?

	Yes
	No

Do you require lifting?

	Yes
	No

If so, would that be partial or total lifting?

	Partial lifting
	Total lifting

Do you have a hoist?

	Yes
	No

Name of hoist 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?)

Type of heating

Washing machine?

	Yes
	No

Drier?

	Yes
	No

Refrigerator?

	Yes
	No

Freezer?

	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

If so, please give details of pets

Are there any other domestic staff?

	Yes
	No

What accomodation 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?

	For up to 3 months
	For 3 months or longer

COMPLETE THIS SECTION ONLY IF THERE IS ANOTHER PERSON IN THE HOUSEHOLD WHO REQUIRES CARE

Title

Forenames

Surname

Date of birth

STATE OF HEALTH OF CLIENT

Weight

Height

Is help required during the night?

	Yes
	No

If so, please indicate number of times per night help is required

Or indicate number of times per week help is required at night

Do you use a commode?

	Yes
	No

Do you use a wheelchair?

	Yes
	No

Do you use a Zimmer frame or any other walking aid?

	Yes
	No

Do you require lifting?

	Yes
	No

If so, would that be partial or total lifting?

	Partial lifting
	Total lifting

Do you have a hoist?

	Yes
	No

Name of hoist 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

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

Thank you for your co-operation in completing this form

Please enter the word that you see below.