Adult Query

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
Assessment Direct
Effingham Square
Rotherham
S65 1AW Wath Locality Office
Wath Town Hall
Church Street
Wath
S65 7RE Maltby Locality Office
Maltby Civic Centre
High Street
Maltby
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:

2OT5M46875

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:

Do you have any specific cultural needs?

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 your finances

What is your national insurance number?

Who managers your day to day finances?

Who has legal authority over your finances?

Part D

Tell us about the people who live or care for you

First 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:

Second 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 E

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:

What internal or external security precautions have you taken?

Do you feel harassed or threatened in your home?

If yes please explain:

Is Rothercare installed in your home?

Can you identify any safety hazards in your home?

Do you have any assisted technology installed in your home?

Have you been issued or purchased any adaptations in your home?

Please provide any additional information about your home:

Part F

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 G

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 H

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 I

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 J

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 K

Tell us about your leisure interests and work / learning opportunities

What leisure activities or hobbies do you participate in?

Are you able to successfully pursue work opportunities?

Part L

Tell us about your health

Describe any problems with your current mobility?

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

Do you have any mental health concerns or take any medication as a result of a mental health issue? eg depression

Have you experienced any significant changes in weight?

Describe any specific dietary needs?

Part M

Tell us about your current condition

Do you have heart problems?

Do you have leg ulcers?

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

Can you leave your home without assistance?

Do you have problems with your memory or get confused?

Would you say the general state of your health was good?

Part N

Tell us about your Emotional and Physical Behaviours

Are you prone to changes in mood?

If so how do you express this?

Describe any phobias or anxieties?

Part O

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 P

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 Q

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
Assessment Direct
Effingham Square
Rotherham
S65 1AW Wath Locality Office
Wath Town Hall
Church Street
Wath
S65 7RE Maltby Locality Office
Maltby Civic Centre
High Street
Maltby
S66 8LE