Service User Enquiry Form

Full Name of Person Making the Enquiry

Full Name of Service User

Preferred Name of Service User

Service User Address

Service User Postcode

Phone Number of Person Making the Enquiry

Service User Phone Number

Email of Person Making the Enquiry

Service User Email

Explain the Enquiry (Is this a Social Work Referral, a private enquiry, a private enquiry with a local authority budget, or a hospital discharge.)

Has a Local Authority Budget been approved or is the support to be paid privately

Name of enquirer and relationship to the service user (If Local Authority, what locality and social worker) if this is a self referral please write N/A

Main contact / Next of Kin (Please state their Name and contact details and if you wish for them to be contacted regarding this enquiry).

Is there a Power of Attorney or Guardianship order in place. Does the person have capacity.

Current Situation

Does the person live alone, with family, partner/spouse, or other? Are there any pets within the home.

Is anyone currently providing care? If so, who and/or why is a change or increase required?

Has the person received care in the past?

What are the access and egress arrangements from the home i.e. a key safe is in place

Medical Information

What medical conditions or diagnoses does the person have? How does this affect them?

Does the person take prescribe medication and will JKL be required to prompt or administer this. Please provide details. (Include any prescribed creams). (Be aware JKL cannot carry out any unprescribed medication regimes).

Has the person been hospitalised in the past 6 months?

Support Required

What support is needed? (e.g. personal care, medication support, meal preparation, mobility support, toileting/continence care, companionship, domestic support, shopping etc.)

Mobility

Can the person walk independently? Can they get in and out of bed independently?

Does the person use any equipment? (e.g. walking aid, wheelchair, hoist, standing aid etc.)

How many carers are required to support mobility/moving & handling? Please describe any moving and handling support that will be required.

Care Requirements

Days support is required

Will these visits require one or two carers and for how long.

Is the support required urgently? Please explain if so.

Will meal preparation be required and if so who will carry out the persons shopping

Do they have any allergies or dietary requirements

Risks

Any risks staff should be aware of? (e.g. smoking, pets, aggression, unsafe access, previous AP1)

Funding

How will care be funded? (e.g. Private, Social Work, Direct Payments/SDS, Unsure)

Is there anything else you feel we should know before arranging an assessment?

Please provide availability for contact to be made