NEEDS ASSESSMENT - DOMESTIC SUPPORT / HOME HELP

Client Form [Domestic Support and Home Help]
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.
Scope of Service:
This service is strictly limited to non-regulated domestic activities and home help. It does not include personal care, medication support or clinical interventions.

If the service user's needs change and support with regulated activities becomes necessary, a separate needs assessment must be completed and a new care agreement established before such support can begin.
1. Client and assessment details
Forename and Surname
Preferred name
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Address and postcode
Telephone
Email Address
example@example.com
Emergency Contact/ Phone
2. Requested domestic support (tick)
Tick all requested tasks
Any other tasks not on the list:
3. Schedule and arrangement
Requested days of Visit
Preferred visit times
Duration of visits
Any other specific instructions for Support worker
Signature
Should be Empty:

Client Form [Domestic Support and Home Help]