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My Care Account

Needs Assessment

Please complete as much information as you are able to.

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1Needs Assessment 2Reason for Contact

Needs Assessment

If you are completing this form on behalf of someone else, please provide information about this person

Before creating an account or logging in to that account, please confirm:

Are you completing this form for yourself or someone else? * This field is required

Myself

Someone Else

Please note the below information is about the person who the assessment is about:

Is your gender identity the same as the gender you were assigned at birth?

What pronouns do you use?

Please describe the home you live in (e.g. who you live with, are you a homeowner)

Is this assessment combined for yourself and your carer? * This field is required

Yes

Communication

Do you need an interpreter? * This field is required

Yes

Do you consider yourself to be any of the following?

Are you registered?

Blind

Partially sighted

Do you have any other communication difficulties you would like to tell us about?

Does anybody help you to make decisions? * This field is required

Yes

Is there anybody you would like us to tell about this assessment? * This field is required

Yes

Tell us how you make important decisions in your life * This field is required

Do you have a Lasting Power of Attorney or Deputyship for Health and Welfare in place? * This field is required

Yes

Do you have an Enduring Power of Attorney/ Lasting Power of Attorney or Court of Protection Deputyship for Property and Affairs in place? * This field is required

Yes

Health Information

Have you been prescribed any medication?

Yes

Do you use any equipment/technology in your everyday life? * This field is required

Yes

Please note that to enable us to progress your enquiry effectively, we will require details of your GP.

Name of your GP / GP Surgery:

GP Address: * This field is required

GP Postcode: * This field is required

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