Astra Homes Ltd · Choice Control Finance Leisure Education Employment Family, Social Roles...

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Astra Homes Ltd Application Form & Assessment of needs Pinfold Home 33-37 Pinfold Road London SW16 2SL

Section A Enter Service User Details

Surname

Forename

Title

Date of Birth

Marital Status

National Insurance No

Gender

Current Address

Address

Address

Address

Post Code

Accommodation Type

Ethnicity

Primary Needs

Do you need assistance with communication Yes No If Yes, please give details:

Name

Address

Address

Post Code

Relationship

Next of kin

Home phone

Work phone

Family Doctor

Name

Address

Address

Post Code

Telephone No

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Section B Background, Current needs

Current Needs / Presenting Problems

Personal History

3


Section B (cont) Background, Current needs

Person’s view about presenting needs

Views of other organisations or professionals about presenting needs

4


Section C Assessment

Safety, Abuse, Neglect

Relevant History? Problems, issues or risks? Persons strengths, abilities, motivation? Is a specialist or further assessment required? Yes No

5


Section C (cont) Assessment

Physical Health


6



Mental Health


7



Personal Care


8



Leisure, Education, Employment, Training


9



Family, Social roles and Responsibilities


10



Support networks, Religious and Cultural Needs and Relationships


11

Summary of problems, strengths, risks to independence and support currently provided



Section D Risks, Needs, Eligibility

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Section D (cont) Risks, Needs, Eligibility

Critical Substantial Moderate Low N/A

Summary of Risks and Eligibility & Care Criteria

Safety, abuse, neglect

Physical health

Mental health

Personal care

Domestic routines

Home environment

Choice

Control

Finance

Leisure

Education

Employment

Family, Social Roles

Religious / Cultural Needs

Overall Risk

Is any immediate action required?

Yes No If yes, state what and when

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Section D (cont) Risks, Needs, Eligibility

Does the Service User disagree with assessment or wish to make comments

Yes No If yes, explain

Is the Service User happy to share information with other organisations to help with the assessment

Yes No If no, please explain why

Details of any information or advise offered, or referrals made

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Section E Daily Living Skills

Please comment on how the person currently manages the following tasks

Getting around the home

Does the person use any walking equipment? Yes No

1 Able to manage

2 Able to manage but difficult

3 Able to manage with help

4 Unable to manage

1 2 3 4

Using steps / stairs

1 2 3 4

Getting in and out of chairs

1 2 3 4

Using steps / stairs

1 2 3 4

Washing themselves

1 2 3 4

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Section E (Cont) Daily Living Skills

Getting in and out of bed

1 2 3 4

Preparing hot drinks/ snacks/ meals

1 2 3 4

Eating drinking

1 2 3 4

Housework

1 2 3 4

1 Able to manage



4 Unable to manage

Laundry

1 2 3 4

Shopping

1 2 3 4

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Section E (Cont) Daily Living Skills

Collecting Benefits / Paying Bills

1 2 3 4

Eyesight

1 2 3 4

Hearing

1 2 3 4

Communication

1 2 3 4

1 Able to manage



4 Unable to manage

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Section F Financial Check List

Benefit £

Income support £

Job seekers allowance £

Disability Living Allowance

Care £

Mobility £

Attendance Allowance £

Invalid Care Allowance £

Incapacity benefit £

Severe disablement allowance £

Family Credit £

Child Benefit £

Widows pension £

Retirement pension £

Council tax benefit £

Housing benefit £

Occupational pension £

Independent living fund £

War disability pension £

Reduced earning allowance £

Industrial injuries disablement £

Constant Attendance Allowance £

Other £

Amount

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Section G Declaration

Signature of the person being assessed Name

Signature

Date

Astra Homes Ltd · Choice Control Finance Leisure Education Employment Family, Social Roles...

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