SLIC - CARER REQUEST FORM

SLIC - CARER REQUEST FORM
Name of Your Office:*
Dependency Level of Package:*

StandardHigherPalliative & ComplexCouplesNight - HigherNight - StandardNight - CouplesNights - Palliative & Complex
Your Office Phone Number*
Please enter a valid phone number.
Location / Closest Train Station Where Carer Will Work:*
Start Date:*

DayMonthYear
Date
End date

DayMonthYear
If applicable
OR Number of Weeks in Placement
If applicable
What Time Will the Carer Need to Arrive at Station/ Customer Home: *

Please note if you require a carer to arrive before noon, with less than 48 hours notice then a travel contribution charge of £20 minimum will be applicable.

AM/PM Option
Sex of Carer*

FemaleMaleEither
Does the Carer Need to Drive? *
If Driver is Required, we would need a minimum of 4 weeks to source a driver
Will the Carer Be Required to Use Their Own Car?

YesNo
Any Additional Specialised Experience, Training and Qualifications Required for Carer to Fill the Position?
Example: PEG Feeding, Stoma care etc
Details of any additional expenses to be paid to Carer or additional services required :
Example: mileage rate if carer is using own car & how its paid
Will the carer be using an Electronic Care Note system?*
If Yes, Which Electronic Care Note system?
Your Customers Surname: *
Does the Customers Home have WIFI in their home? *
Does the Customer Have Any Pets?*

YesNo
If, Yes which Pets?

DogCatOther
Does the Customer Smoke or Vape?*

YesNo
Customers Summary:*
Administration of Medication?*

Customer Self AdministersCarer to PromptCarer to AssistCarer to AdministerNo Medication
Does Customer Need Support with Manual Handling*

YesNo
If Manual Handling Support is Needed, What Support is Required?
Live-in Carer is entitled to a two hour daily break, what is the arrangement? *
If other arrangement in place for carers two hour daily breaks please explain:
CCL/Supervisors Name *

First NameLast Name
CCL/Supervisors Email*
Please enter a valid email address for all future communications regarding this request to go to.
CCL/ Supervisors Phone Number*
Please enter a valid phone number.
Emergency Out of Hours Phone Number*
Please enter a valid phone number.
Your company are required to ensure the live-in carer is provided with a separate bedroom with a bed and clean bed linen; and cleaning supplies. Live-in carers require a minimum of 2 hours break in each working day (14 hours a week). This time off should be taken during daylight hours or at a mutually agreed time. Any additional service required by your customer (for example carers fuel cost whilst in placement, night disturbances between 10pm - 7am, no cover available for live-in carer daily 2 hour break) will need to be discussed with a member of our team before the start of the placement, with all associated additional costs being borne by your company.

I CONFIRM THAT THE INFOMATION I HAVE SUPPLIED ABOVE IS TRUE & TO THE BEST OF MY KNOWLEDGE
Name of Your Office:*
Food Allowance arrangements:*

Customer will give them £40 per week Cash.Carer to supply shopping list for customer / family member to do the weekly shop.Carer to invoice SLIC for the £40 weekly food allowances (this will be charged to the you)Other
If other arrangement in place for carers food allowance please explain:
Form Completed By*

First NameLast Name
Signature*

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