Home From Hospital Householder Form

Home From Hospital Householder Form
Full Name*
What name would you like to be addressed by?
Date of Birth

MonthDayYear
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Phone Number*

Area CodePhone Number
Mobile Number
Email
example@example.com
Nationality
Religion
Primary Language
Location/transport
(closest train or tube station and distance from these)
HOUSEHOLDER/FAMILY CONTACTS

Please list below the names, addresses and relationship of all nominated contacts.
Nominated Contact
We ask that you indicate what level of contact each person has ie: Day-to-Day or only in an emergancy.
Nominated Contact
We ask that you indicate what level of contact each person has ie: Day-to-Day or only in an emergancy.
HEALTH INFORMATION
Reason for being in hospital and current symptoms*
Detail of any other illness, disabilities, incontinence, mobility issues, falls/history of falls, memory loss etc:
NB: Sharers are not permitted to give hands-on personal care, such as lifting, bathing and feeding. Sharers may not administer medication. Medication should be in pharmacy-prepared blister packs.
Discharge information from hospital
(including any extra support in place and how long; ability to do things)
Likely Hospital Discharge Date
Start Date of Home from Hospital arrangement:
If preferred, the Sharer could move in before the discharge date so they are already in place to welcome the Householder home. Please NOTE once a match is agreed the Householder has a responsibility to let the Sharer move in regardless of if they stay longer in hospital.
SUMMARY OF REQUIREMENTS
Brief description of why a Home from Hospital Homesharer is required? *
(Sharers will normally be available evenings only with a few hours at the weekends. The Sharer's role is to give reassurance of someone in the property overnight. They can also give up to 15 hours per week of practical and company-such as cooking, shopping, admin, light cleaning and tidying, running errands- over the course of 5 evenings each week and a few hours at the weekends. The Sharer is allowed one weekend away each month during a Home from Hospital arrangement, with prior agreement. Please consider how you would manage in their absence.)
Give details of personal outcomes the Householder hopes to achieve by having a Home from Hospital Sharer:
Existing support: carer/cleaner/gardener/family*
Include care package times and duration
Family involvement in supporting the Householder and how given:
What would be your preferred Sharer?*

MaleFemaleNo preference
MORE INFORMATION ABOUT THE HOUSEHOLDER
What time do you usually get up in the morning and go to bed in the evening?
What time do you usually eat your evening meal?
A short introduction to yourself:*
Tell us about your family, what your profession is/was, your hobbies and interests
Any major dislikes?
Do you, or any regular visitors, smoke in the house?

YesNo
Do you have any pets?
If yes please give details of the pet/s
COOKING/DIETARY REQUIREMENTS
Would you like your Sharer to cook?*

YesNoSometimes
Any allergies or special dietary requirements?
(such as gluten free, nut free, vegetarian, vegan, religious)
Favourite dishes:
English meals, spicy food, Italian etc
Dislike dishes:
DETAILS OF ACCOMMODATION
Is the accommodation a house/flat?

HouseFlat
Do you own the property?

YesNo
Council Tax Band?*
Home From Hospital temporary Sharers confirm they have a main residency elsewhere so you should not lose your single person discount.
General condition of the property (please select if Yes)*

Is it very clean?Is it moderately clean?Is it not very clean?Is the property cluttered?Is there any mould in the bedrooms/living spaces?Can the windows be opened in the Sharer's bedroom?Are there any trip hazards that need to be discussed/addressed?
Are there any cameras in the property?*

YesNo
Is there broadband in the property?

YesNo
About the accommodation available for the Sharer (please select if Yes)*

Does the room have a single bed?Does the room have a double bed?Is there a desk and chair in the Sharer's room?Is the bathroom shared?Is the bathroom for Sharer's own use?Is there a separate showerIs there a shower attachment over the bath?
SAFETY/SECURITY IN THE HOME
Are there working smoke alarms on each floor of your home?*

YesNo
Is your boiler/gas oven serviced annually by a Gas Safe registered engineer?*

YesNo
Are there working carbon monoxide alarm in rooms with a gas boiler or usable fireplace?*

YesNo
Is there a fire extinguisher or fire blanket in the property?*

YesNo
Is the furniture provided for the Sharer's use Fire Safety Compliant?*

YesNo
Is there a burglar alarm?*

YesNo
Are there window locks at ground floor level?

YesNo
Is there anyone other than the Householder living in the property?

YesNo
Does the front door have a 5-lever mortise lock?

YesNo
Will there be any equipment in place to aid the Householder?

YesNo
Home insurance (please select if Yes)*

Do you have buildings insuranceDo you have contents insurance?
LEGAL INFORMATION
Additional Information (please select if Yes)*

Does the Householder have mental capacityDoes the Householder give consent for the Registration?Are we given permission by the Householder to share information about the Homeshare arrangement with a nominated representative?
Nominated Representative Required*
Please give Name, Address, Telephone No and email address. Also indicate relationship to Householder.(Please note: If the Householder has Mental capacity, they must have given this permission.)
Is there a Power of Attorney in place?(if Yes please advise contact details of the POA'S)
Please send us a copy of the POA certificate
Please ensure you have permission of the third parties included on this form to provide their contact details for the purpose of enabling a Homeshare arrangement.*

Please tick to confirm you understand photographs provided will be used in advertising. Please note that we take every effort not to use photographs that could identity the person to the locationPlease tick to confirm you agree to this information being help and used in accordance with Share and Care Homeshare's privacy policy
Sharers are not permitted to provide personal care (such as lifting, bathing, dressing, administering medication or any similar personal care services.) I confirm that I understand the above and I have read and accepted the Term's & Conditions Fee sheet.*

Clear
Upload photographs of the property here (Alternatively you can email photographs to info@shareandcare.co.uk)

We require photographs of the Sharer's bedroom including storage space, the kitchen, bathroom and shared living space. Please also provide a photo of the Householder for ID purposes.
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Home From Hospital Householder Form

HOUSEHOLDER/FAMILY CONTACTS

HEALTH INFORMATION

SUMMARY OF REQUIREMENTS

MORE INFORMATION ABOUT THE HOUSEHOLDER

COOKING/DIETARY REQUIREMENTS

DETAILS OF ACCOMMODATION

SAFETY/SECURITY IN THE HOME

LEGAL INFORMATION