CLIENT PROFILE AND INITIAL NEEDS ASSESSMENT FORMS

Higham Carers Client Needs Assessment Form
Confidentiality Statement:
Information recorded on this form will be treated with the utmost confidentiality, in accordance with our data protection obligations under the General Data Protection Regulation (GDPR) and any applicable local data protection laws.
1.Personal Information
Full Name

First NameLast Name
Date of birth

DayMonthYear
Date
Preferred name
2.Contact Details
Main Permanent Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone Number
Alternative Phone Number (optional)
Email Address
example@example.com
Preferred method of Contact
Key Safe (If Applicable)
3.Important Contacts
GP Information
Next of Kin
NOK main Phone Number
NOK alternative Phone Number (optional)
Next of Kin Email
example@example.com
Other people who are important to you:
Healthcare Teams involved in managing your chronic conditions (for example District Nurses etc)
Social Worker (Name and Phone If Applicable)

Eating and Drinking
Do you need help preparing meals (breakfast, lunch, supper)?
Do you need assistance with eating or drinking?
5. Medical History / Medication
What is your medical history? (Please list all chronic conditions or attach the most recent hospital discharge letter.)
What medication are you currently taking?
Do you have any medication and/or food allergies?
How much assistance do you need with taking medication?
Where is your medication stored? (e.g., blister pack, dosset box, original pack)
Who orders your repeat prescriptions?
Do you have a DNAR form (Popularly Known as the RED form)

YESNO
6.Required Care Visits
How many care visits do you require per day? Please specify your preferred times.
What tasks do you require carers to complete during each visit?(Please list key responsibilities.)

7.Method of Funding
Funding Source: (e.g., Private, Local Authority, CCG) — Please specify who will be responsible for handling invoice payments if it is not you directly.
8. Any other relevant information
Please provide any other relevant information, that you think will help the carers quickly build a supportive relationship with you.
Person Completing this form

First NameLast Name
Signature
Should be Empty:

Higham Carers Client Needs Assessment Form