Adult Query

A to Z of Services

Adult Social Care Services

Are you or someone you know finding it difficult to manage everyday activities?

Would you like further information on the support Neighbourhood and Adult Services can offer you?

If you are over the age of 18 and feel you would benefit from Adult Social Care Services you can request an assessment of your needs. To do this simply complete this form and return it to one of our offices.

Alternatively you can contact us by telephone, 01709 822330 or visit one of our Locality Offices to speak to an Assessment Direct Officer.

Crinoline House
Effingham Square
Rotherham
S65 1AW Wath District Office
Wath Town Hall
Church Street
Wath
S65 7RE Maltby Customer Service Centre
Braithwell Road
Rotherham
S66 8LE

What will happen next?

A member of our Assessment Direct Team will review your completed form and contact you to offer advice and information and advise if an assessment of your needs would be appropriate.

Please complete all parts of this form ensuring the information you provide is accurate. If you are contacting on behalf of someone else please complete the form as the person requesting the assessment.

Reference Number:

PXTKKB5000

Part A

Tell us about yourself

Name:

Address:

	Address Line 1
	Address Line 2
	Town / City
	County
	Postcode

Home Telephone Number:

Mobile:

Date of Birth:

Ethnicity:

If Multiple Heritage or Other please state

Language:

Religion:

Are you requesting as assessment on behalf of someone else:

If yes please provide the following information:

Name:

Address:

	Address Line 1
	Address Line 2
	Town / City
	County
	Postcode

Telephone Number:

Part B

Tell us about your general practitioner

Name:

Address:

	Address Line 1
	Address Line 2
	Town / City
	County
	Postcode

Telephone:

Part C

Tell us about the people who live or care for you

Main Carer

Name:

Relationship:

Telephone:

Address:

	Address Line 1
	Address Line 2
	Town / City
	County
	Postcode

Contact details:

Contact in case of an emergency?

Next of Kin:

Vulnerable Dependent:

Key Holder:

Principal Carer:

Part D

Tell us about your home

What type of property do you live in?

What type of tenancy do you have?

Do you live alone?

Is the access to your property suitable for your needs?

If no please describe why:

Please provide any additional information about your home:

Part E

Tell us about your sight / hearing / communication

Do you have any sight / hearing or communication difficulties?

Do you have any assistive technology or aids to help with this problem?

Would you like to use an interpreter?

Part F

Tell us about your ability to self care

Are you able to wash yourself?

If no what help do you require?

Are you able to dress yourself?

If no what help do you require?

What other self care tasks do you need assistance with?

Part G

Tell us about your daily living

What meals do you currently prepare?

What drinks can you currently prepare?

Are you able to eat without assistance?

Which domestic tasks can you complete in your home?

Can you do your own shopping?

Part H

Tell us about your mobility in your home

What aids or equipment do you use to move around your home?

How do you climb stairs in your home?

Part I

Tell us about your mobility outdoors

What aids or assistance do you need to manage steps in or out or your home?

What aids or assistance do you need to access transport?

Part J

Tell us about your health

Describe your health issues/concerns?

Have you had any recent falls inside or outside your home?

Have you been admitted to hospital in the last 12 months?

Do you have problems with your memory or get confused?

Part K

Tell us what you think

What do you think we could do to meet your needs?

What does your carer or relative think we could do to meet your needs?

Part L

If you are the applicant and have completed this form please complete the section below.

We may share your information with other Rotherham Council Departments. We may also share your information with other public organisations in order to detect fraud and prevent crime. If you do not wish us to share you information please write and tell us.

In signing this form you are agreeing that all information supplied in this form is correct and that you agree to the above statement.

Name:

Date:

Agreement:

Part M

If you are a friend or carer and have completed this form on someone elses behalf please complete this section.

In signing this form you are agreeing that all information supplied in this form is correct and that you agree to the above statement.

Is the person aware you have completed this form on their behalf?

Name:

Date:

Agreement:

Next Steps

An Assessment Direct Officer will review your form and contact you by telephone within 1 working day to offer advice and assistance and advise if an assessment of need is appropriate.

Should you need to contact us again in the future you can in the following ways:
Telephone: 01709 822330
Email: assessmentdirect@rotherham.gov.uk
In person:

Crinoline House
Effingham Square
Rotherham
S65 1AW Wath District Office
Wath Town Hall
Church Street
Wath
S65 7RE Maltby Customer Service Centre
Braithwell Road
Rotherham
S66 8LE