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.Format: 00000 000 000.
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. This is a time request and not a guaranteed time of arrival.

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:*
Please give as much detail as possible. This is used when discussing placement with potential suitable carers.
Will the carer be expected to provide any regular night care?
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.Format: 00000 000 000.
Emergency Out of Hours Phone Number*
Please enter a valid phone number.Format: 00000 000 000.
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*
Should be Empty: