Application and Self Assessment Form Princess Marina House Rustington, West Sussex BN16 2JG

Transcription

1 Office Only Name G CASE # Application and Self Assessment Form Princess Marina House Rustington, West Sussex BN16 2JG Application Form, Self Assessment Form, Financial Assistance Request

2 Application for a Short Welfare Break Princess Marina House, Rustington, West Sussex, BN162JG This questionnaire is strictly confidential and will become part of your medical record. Details of Service on Whom Eligibility is Based Applicant Yes No Name (Last, First, M.I.): M F DOB: I like to be known as Marital status: Single Partnered Married Separated Divorced Widowed Maiden Name : National Insurance Number RAF Service Number: Rank : Branch /Trade From to War Disability Pensioner Yes No If Deceased, Date of Death Please attach photocopy of Death Certificate NHS Number Details of Eligible Applicant (if not above) Relationship to Person at Section A Name (Last, First, M.I.): M F DOB: Date of Marriage National Insurance Number NHS Number Details of any other person accompanying applicant Relationship to Applicant Name (Last, First, M.I.): M F DOB: Date of Marriage National Insurance Number NHS Number 1

3 Address of Applicant Postcode Type of accommodation House Flat Bungalow Care Home Other Home Phone Number Mobile Phone Number Next of Kin/ Other family/ significant other Relationship to Applicant Name Address Telephone Number Friends and Family who support me Name Address Telephone Number Name Address Telephone Number Health Care Professional e.g. Doctor, District Nurse, Social Worker Name Address Telephone Number If you have the following please bring them with you Copy of your Lasting Power of Attorney for health and welfare Copy of your Lasting Power of Attorney for financial affairs A do-not-resuscitate order, (DNR order) written by a doctor. (please note original only will be accepted by health care professionals) Advanced Care Plan 2

4 Your stay Period of stay requested is from to I would prefer to arrive on Monday Tuesday Wednesday Thursday Friday I would like to stay for One week Two weeks Three weeks Four weeks I would like the tariff Full board Half board Bed and breakfast I need days notice or I can accept a cancellation at short notice State briefly reason for break.. How did you hear about Princess Marina House?.. I will be using my own car : registration number: I will be getting a lift I will be coming by train arriving at station I will be coming by coach arriving at Do you need financial Assistance to pay for this? Please see Page 4 if you do If you would like to be assessed for Financial Assistance from the RAFBF to cover the cost of you stay and or transport to Princess Marina House to arrange a case worker appointment please contact RAFA Helpline SSAFA Helpline A case worker will visit you at home to complete Section I of the application form. Please have all documents available. If you don t require financial assistance please just complete and sign Section II and return this booklet to Princess Marina House Enquiries about applications can also be directed to info@rafbf.org.uk or by calling

5 Section I Financial Assessment APPLICANTS WEEKLY HOUSEHOLD INCOME & EXPENDITURE (verified from relevant documents) Is the applicant, to the best of your knowledge, in receipt of all applicable state benefits, rebates and allowances? Yes No What action is being taken? EXPENDITURE Verified Weekly Arrears INCOME Rent (less Housing benefit) Earnings of Applicant (inc. overtime but less Tax and NI) Mortgage Earnings of spouse/partner Council Tax Job Seekers/Income Support Housekeeping Statutory Sick/Maternity Pay Gardener Maintenance received Electricity State Retirement Pension Gas Service Pension Water Rates Occupational Pension Other Fuels War Disablement Pension ( %) Insurance (not NI) Pensions Spouse Television Disablement Pension ( %) Satellite Incapacity Benefit Employment Support Allowance Telephone Widows Pension (War/NI) Broadband Child Benefit/Special Allowance Taxi/Bus fares Working Tax Credit Car Universal Credits Scooter/EPV costs Industrial Injuries Disablement Benefit Personal/Debts/loans/HP Severe Disablement Allowance Hairdresser Disability Living Allowance Care Component Pets (state if guide/assistance Disability Living Allowance dog) Mobility Component House Repairs Attendance Allowance Window Cleaner Disability Working Allowance Cleaner Pension Credit Carer Carers Allowances Prescriptions Other income (give details) Alternative therapy Other (please specify) Total Verified Weekly Total Savings/Capital/Investments Please show amount of savings e.g. Bank, Building Society, etc. Any other long term investments? State what they are 4

6 REPORT OF WELFARE OFFICER/HELPER AND RECOMMENDATION This statement should give a description of the circumstances of the applicant, what the need is and the opinion of the Case Worker. Please use an additional sheet, if necessary. Signature Mr/Mrs/Miss/Mrs/Other Name Address Postcode Address Branch Telephone Date 5

7 Section II Personal Health History (Applicant) Have you ever been diagnosed with any specific medical conditions or ongoing difficulties with : Alzheimer s Disease (Carers please fill in section About Me ) Arthritis/ Joint Replacements/ Fractures Asthma Bowel Disease Dementia (Carers please fill in section About Me ) Depression Diabetes Epilepsy Heart Disease High Blood pressure Kidney Problems Neurological Disorders Obsessive Compulsive Disorder Parkinson s Disease PSTD Recent Surgery Respiratory Disease Skin Conditions Stroke/TIA s Urinary Tract Infections Other (please name) Wound Care Please advise if you have any wounds or ulcers that will require attention during your stay. Yes I have dressings Where?.. They require changing When?.. I have no dressings 6

8 Personal care Do you have professional carers visiting you at home? Yes No If yes, how many times each day? Please state number of times. I do not currently have any support at home. I have part time family member or friend who helps me at home times a day I have a family member or a part time carer who helps with my personal care and other issues around the home times a day I have a live in family member or full time carer or I currently live in a care home and am supported 24 hours a day times a day Washing and Bathing I can bathe independently. Go to the next question I can shower independently but require assistance for a bath. I require the assistance of one carer to maintain my personal hygiene. I require the assistance of 2 carers to maintain my personal hygiene. Dressing I can dress independently. Go to the next question I need support with zips, buttons and hosiery. I require the assistance of one carer to help me dress I require the assistance of 2 carers to help me dress. The support I need with things like dressing, washing and teeth cleaning is... 7

9 Toileting I am independent Go to the next question I am independent with a toilet frame or raised seat. Go to the next question I require the assistance of a carer. I require the assistance of two carers and a commode at night. Continence I am continent Go to the next question I use pads to maintain my independence. Go to the next question I am incontinent of urine and require assistance from a carer and continence aids. How I use the toilet when I am well e.g. continence aids and getting to the toilet I am doubly incontinent and require full assistance from two carers.... Additional Information Protection to bed Pads used Catheter Stoma Bag Weight Under 12 stone 12 to 15 stone stone Over 20 stone 8

10 Eating & Drinking Do you have any special dietary requirements? Yes No Diabetic Yes No Gluten Free Yes No Low Fat Yes No Other (Describe) Please attach your diet sheet I can eat and drink independently. Yes No Providing food is cut up I can eat and drink independently. Yes No Providing food is liquidized I can eat and drink Yes No independently. I require some assistance with eating and drinking. Yes No I require supervision at all times while I am eating and drinking. Yes No Do you have any food allergies. If yes please write them here Yes No Choking If there is a risk you may choke please give details of your management plan and seating & posture 9

11 Medication I do not take any medication I do take medication and I am able to self medicate I will need reminding to take my medication but I am able to give it to myself My medication needs to be given to me by my carers One tablet at a time On a spoon Via a syringe I need help to make sure I have swallowed Have you been prescribed any of the following drugs in the last two years? Sedatives/Tranquilisers e.g. Trazidone, Diazepam, Lorazepam, Estazolam Yes No Anti psychotic drugs e.g. Chlorpromazine Amisulpride, Haloperidol, Pimozide, Trifluoperazine Sulpiride Clozapine Olanzapine Quetiapine, Risperidone Yes No Remember to bring with you An up to date repeat prescription All your medication in a pharmacists blister pack or original packaging List your prescribed medication or attach a copy of your most recent prescription. Name the Drug Strength Frequency Taken Allergies to medications Name the medication Reaction You Had 10

12 Mobility Please bring your own walking frame/rollator. We are unable to provide these for you I have no mobility issues. I am mobile both indoors and outdoors without assistance. Go to the next question I am mobile with the use of an aid indoors and am able to sit and stand independently. Please indicate type of aid in box below headed additional information I am mobile with an aid but require assistance in getting up and sitting down and transferring. Please indicate type of aid in box below headed additional information. I have no mobility without carer and assistance. Please indicate type of aid in box below headed additional information. Are you able to use stairs? Yes No Are you a wheelchair user? Yes No Is your wheelchair electric? Yes No Do you require an electric mobility scooter if available? Yes No Yes No Do you require wheelchair if available? Additional Information e.g. What equipment do you use in your home? Walking stick Profiling or Hospital Bed Crutches Standing Hoist Zimmer Frame Full Body Hoist Turntable Wheeled Frame History of falls No history of falls Go to the next question I have occasional falls but I am usually able to get up unaided I fall frequently but I am usually able to get up unaided If I fall I need to be hoisted 11

13 Keeping me safe - Do I explore? Could I fall out of bed? Please consider environmental risks Sleep Patterns I have no problems with my sleep pattern. Go to the next question I have occasional problems with sleeping. I take medication to sleep well at night. I may require some reassurance at night. How I usually am for example do I sleep a lot, am I usually very quiet? I have trouble sleeping at night and may require support from a carer. Communication Sight No sight issues. I wear glasses/contact lenses and require carer support with these and help cleaning them I am registered blind / partially sighted and require assistance from the carers. I am blind / partially sighted and use a guide dog and will require support from the carers. Hearing Speech I have no hearing issues. I have no speech issues. I can communicate without help. I have hearing aids /issues but manage with minimal help. I know how to put it in and turn it on I have speech difficulties but can communicate without difficulty. I have hearing aids / issues and need assistance putting it in and turning it on My speech is distorted and may require extra support to be understood. I am registered as being deaf and require a large amount of support. I am unable to verbally communicate I communicate using aids. 12

14 Other ways I communicate Signing, pictures or other languages? How I show how I feel. How I communicate yes and no. Understanding I have no problems understanding people or remembering information I have occasional difficulty remembering information I have memory loss which affects my day-to-day living and / or I have been diagnosed with dementia in the last two years. I have memory loss which affects my ability to care for myself and/or have been diagnosed with dementia more than two years ago. How I show I m in pain and how to support me 13

15 About Me Are you prone to infection? Yes No If yes, Urine Chest Other In the event of an infection have you ever Become verbally aggressive? Become paranoid (suspicious of people around you)? Become delusional? Thrown or broken anything? Hit out at person/persons? How do you react to strange places? Yes Yes Yes Yes Yes No No No No No Do you become anxious at any particular time of day? Yes No If yes, when? How is this displayed? tick any box Wandering Inability to sit still Constant questioning Accusations of persecution Verbal aggression Throwing things Hitting out Things that may worry or upset me How I may show this 14

16 How to support me if I am anxious or upset Behaviors I have that may be challenging or cause risk. What you can do to support me with my behaviors things that help me relax If this section is completed by a family member or carer please sign in the box below Signature Date Relationship to applicant 15

17 My likes and dislikes Things I like could include: Music, TV foods, activities and how I relax Things I don t like could include: Things that worry me, foods, activities and ways I don t like being treated My History- What is important that you know abut my life (past and present) including previous employment 16

18 This certificate must be signed in order to process your application CERTIFICATE (can be read out to the applicant) I declare that the information I have given on this form is correct to the best of my knowledge. I agree that the information supplied on this form may be shared with voluntary or charitable organisations and relevant statutory agencies for the purpose of furthering my application for assistance. I agree that the information supplied on this form may be shared with the Ministry of Defence and its agencies, including Service Personnel and Veterans Agency, for the purpose of verifying my service in the Armed Forces. I agree that information collected as part of the application process may be retained so that any future applications may be speedily processed, and that data generated may be used for follow up assistance, statistical and research purposes. I confirm that the information I have provided in the above assessment is a true indication of my care needs. I give permission for The Royal Air Force Benevolent Fund to contact my GP or any other Health Care Professional if there are any concerns relating to the information I have given. Applicants Signature Date Declaration Data Protection Act The information provided by the applicant is given in confidence and is subject to the Data Protection Act. The Royal Air Force Benevolent Fund may share this information with third parties in order to seek/secure further funding. Thank you for taking the time to complete this form. 17