Rainbow Direct Care
Online Assessment
Online Assessment

We have designed the Online Care Assessment Form to simply the process of assessing your needs. Once completed the information you have entered will be reviewed by a member of our Assessments who will contact you to discuss your requirements further.

Any information that you provide will only be used for the purposes of assessing your care needs. All information is securely processing and stored in accordance with the Data Protection Act and Rainbow Direct Care Privacy Policy.

All fields marked with (*) are mandatory and should be completed. Alternatively you can arrange for us to visit you and carry out the assessment in person or we can conduct a telephone assessment.

    Personal Details

    Title*:

    Other:

    Forename(s)*:

    Surname*:

    Gender*:

    MaleFemale

    Date of Birth (DD/MM/YYYY)*:

    Religion:

    Ethnicity:

     

    Contact Details

    House Number/House Name*:

    Street Name*:

    Town/City*:

    County*:

    Postcode*:

    Contact Number*:

    Other Telephone Number:

    Email Address*:

     

    GP Details

    GP Surgery:

    Name of GP:

    GP Telephone:

    GP Address:

     

    Self Assessment

    The following sections of this Self Assessment will assist us in determining the correct level of support you may require to meet your needs. Please complete as many of the following questions as possible and use each text area if you wish to provide us with further information.

     

    Meals

    Do you require help preparing meals?

    YesNo

    Laundry

    Do you require help with laundry?

    YesNo

    Washing/Bathing

    Do you require help washing/bathing?

    YesNo

    Clothing

    Do you require help putting/taking off clothing?

    YesNo

    Shaving

    Do you require help shaving?

    YesNo

    Using The Toliet

    Do you require help using the toilet?

    YesNo

    Cleaning

    Do you require help cleaning the house?

    YesNo

    Shopping/Groceries

    Do you require help with your shopping?

    YesNo

    Travelling

    Do you require help travelling?

    YesNo

    Finances

    Do you require help with paying bills?

    YesNo

    Benefits

    Do you require help with benefits?

    YesNo

    Housing

    Do you require help with housing?

    YesNo

    Gas/Electricity and Water

    Do you require help with Gas, Electicity and Water?

    YesNo

    Chiropody/Podiatry

    Do you require help with Chiropody/Podiatry?

    YesNo

    Dental Health

    Do you require help with your dental/oral health?

    YesNo

    Disability

    Do you consider yourself disabled?

    YesNo

    Mental Health

    Do you have any mental health problems?

    YesNo

    Mobility Indoors

    Do you require help moving inside the house?

    YesNo

    Mobility Outdoors

    Do you require help moving outside of the house?

    YesNo

    Medication

    Do you require help with taking your medication?

    YesNo

    Sight/Vision

    Do you any difficulties with your sight?

    YesNo

    Hearing

    Do you have any difficulties with your hearing?

    YesNo

    Talking/Speech

    Do you have any difficulties with your speech?

    YesNo

    Reading

    Do you require help with reading?

    YesNo

    Sleeping

    Do you have any trouble sleeping at night?

    YesNo

    Remembering/Memory

    Do you have problems remembering things?

    YesNo

    Safety/Security

    Do you have any concerns about safety and security in
    your home?

    YesNo

    Neighbourhood

    Do you have any issues about neighbours, Anti Social
    Behaviour, Parking, Bins etc?

    YesNo

    Driving

    Do you require help with driving you car?

    YesNo

    Companionship

    Do you require someone to accomapny you to places like
    shops, movies, church or pub?

    YesNo

    Residence

    Where are you currently living?

    Own HomeFamily/FriendsCare/Residential HomeSupported Living/HousingOther

     

    More Information

    Do you have any medical or health issues?

    YesNo

    Do you recieve help and assistance from family members
    or friends?

    YesNo

     

    If there is anything further that you would like to tell to help us determine your needs, please tell us below.

     

    Services Required

    Home Care:Managed Live In Care:Respite Care:Palliative Care:Nursing Care:Learning Disabilities:Specialist Care:Companionship Care:Transition - Home From Hospital:Dementia and Alzheimer's Care:Extra Care - Supported Living:

     

    Are you happy for us to contact you to discuss about your needs further?

    YesNo

     

    What Happens Next

    A member of our Assessment team will review the information you have provided and get back to you to discuss your requirements further.