Request a Care Assessment

1

Referrer / Requester Information

The person making this request.

First name *

Last name *

Relationship to client *

Phone *

Email *

2

Client / Service User Information

Details of the person who will receive care.

First name *

Last name *

Date of birth *

Gender *

Street address

Address line 2

City

Region / county

Postal code

Country

Email

Phone

Preferred language

NHS number (if available)

3

Living Situation

Current living arrangement

Type of housing

Accessibility of home

4

Health & Care Needs

Primary health conditions / diagnoses

Current medications (if known)

Allergies

Mobility status

Independent, walking aid, wheelchair, bedbound

Personal care needs

Washing, dressing, continence, toileting

Nutrition / meal preparation support

Communication needs

Hearing impairment, speech difficulties, visual impairment, other

Mental health / cognitive needs

Dementia, memory issues, learning disabilities, autism, mental illness, other

Risk factors

Falls, challenging behaviour, substance misuse, safeguarding concerns

5

Current Support

Does the client currently receive any care or support? *

If yes, please describe

GP name and surgery

Other professionals involved

Social worker, occupational therapist, district nurse, etc.

6

Requested Support

Tick all that apply.

If other, please specify

Preferred start date *

Preferred days / times of support

7

Emergency Contact / Next of Kin

First name

Last name

Relationship to client

Phone

Email

8

Consent & Declaration

I consent to Bluezone Care progressing this assessment request. *I consent to the agency contacting me and securely storing this information.I consent to information being shared with relevant professionals (e.g. GP, district nurse, social worker).

Form completed by

Date form completed *

Additional details

Home Care

Live-in Care

Complex Care

Community Services