application and self assessment form princess marina house ... · where the ex-service person has...
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Application andSelf Assessment Form Princess Marina House Rustington, West SussexBN16 2JG
Print Name (First, Middle Initial, Surname)
…………………………………………………………………………………….
Application Form, Self Assessment Form, Financial Assistance Request
Office Only G CASE #
1
Application Form for a Short Welfare Break
Princess Marina House, Rustington, West Sussex, BN16 2JG
01903 784044 01903788970 www.rafbf.org/princess-marina-house
This questionnaire is strictly confidential and will become part of your medical record.
Details of Service on Whom Eligibility is Based Applicant Yes No
Name (First, Middle Initial, Surname):
F
DOB: __________________
Marital status:
Single Partnered Married Separated Divorced Widowed
Maiden Name :_________________
RAF Service Number: ______________ Rank : ________________ Branch /Trade ________________ From to
War Disability Pensioner Yes No
If Deceased , Date of Death _________ New applicants only, please attach photocopy
of Death Certificate
NHS Number
Details of Eligible Applicant (if not above) Relationship to Person at Section A __________
Name (First, M.I. Surname): _____________________________M F DOB: _________
Date of Marriage _____________
NHS Number
Details of any other person accompanying applicant Relationship to Applicant _________________________ Date of Marriage _____________
Name _____________________________M F DOB: _________
NHS Number
Address
M
(First, M.I. Surname):
2
Address of Applicant ______________________________________________________________________________
____________________________________________________________Postcode_____________ Email Address
Type of accommodation House Flat Bungalow Care Home Other __________
Home Phone Number _________________ Mobile Phone Number ______________________
Next of Kin/ Other family/ significant other Relationship to Applicant ______________ Name ________________________________________________________________________ Address _______________________________________________________________________ Telephone Number ______________________________________________________________ Friends and Family who support me Name ________________________________________________________________________ Address _______________________________________________________________________ Telephone Number ______________________________________________________________ Name ________________________________________________________________________ Address _______________________________________________________________________ Telephone Number ______________________________________________________________
Health Care Professional e.g. Doctor, District Nurse, Social Worker Name ________________________________________________________________________ Address _______________________________________________________________________ Telephone Number
If you have the following please bring them with you
Copy of your Lasting Power of Attorney for health and welfare
Copy of your Lasting Power of Attorney for financial affairs
A do-not-resuscitate order, (DNR order) written by a doctor. (please note original only will be accepted by health care professionals)
Advanced Care Plan
3
Your stay
Period of stay requested is from _____________________to_____________________
I would prefer to arrive on Monday Tuesday Wednesday Thursday Friday
I would like to stay for One week Two weeks Three weeks Four weeks
I would like the tariff Full board Half board Bed and breakfast
I need ____________ days notice or I can accept a cancellation at short notice
State briefly reason for break
…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………..
How did you hear about Princess Marina House?
I will be using my own car : registration number:
I will be getting a lift
I will be coming by train arriving at ___________________ station I will be coming by coach arriving at ___________________
Do you need financial Assistance to pay for this ? Please see Page 4 if you do
If you would like to be assessed for Financial Assistance from the RAFBF to cover the cost of you stay and or transport to Princess Marina House to arrange a case worker appointment please contact RAFA Helpline 0800 018 2361 www.rafa.org.uk SSAFA Helpline 0800 731 4880 www.ssafa.org.uk A case worker will visit you at home to complete Section I of the application form. Please have all documents available. If you don’t require financial assistance please just complete and sign Section II and return this booklet to Princess Marina House Enquiries about applications can also be directed to [email protected] or by calling 0800 169 2942
4
Section I
Financial Assessment APPLICANTS WEEKLY HOUSEHOLD INCOME & EXPENDITURE (verified from relevant documents) Is the applicant, to the best of your knowledge, in receipt of all applicable state benefits, rebates and allowances?
Yes No What action is being taken?
………………………………………………………………………………………………………………………....................................
Owner occupier or tenant ?...................................................................................
EXPENDITURE Verified Weekly Arrears INCOME Verified Weekly
Rent (less Housing benefit) Earnings of Applicant (inc. overtime but less Tax and NI)
Mortgage Earnings of spouse/partner
Council Tax Job Seekers/Income Support
Housekeeping Statutory Sick/Maternity Pay
Gardener Maintenance received
Electricity State Retirement Pension
Gas Service Pension
Water Rates Occupational Pension
Other Fuels War Disablement Pension ( %)
Insurance (not NI) Pensions – Spouse
Television Disablement Pension ( %)
Satellite Incapacity Benefit Employment Support Allowance
Telephone Widows Pension (War/NI)
Broadband Child Benefit/Special Allowance
Taxi/Bus fares Working Tax Credit
Car Universal Credits
Scooter/EPV costs Industrial Injuries Disablement Benefit
Personal/Debts/loans/HP Severe Disablement Allowance
Hairdresser Disability Living Allowance – Care Component
Pets (state if guide/assistance
dog) Disability Living Allowance –
Mobility Component
House Repairs Attendance Allowance
Window Cleaner Disability Working Allowance
Cleaner Pension Credit
Carer Carers Allowances
Prescriptions Other income (give details)
Alternative therapy
Other (please specify)
Total
Total
Savings/Capital/Investments Please show amount of savings e.g. Bank, Building Society, etc.
Any other long term investments? State what they are ________________________________
£
£
5
Welfare officer/helper’s report and recommendation
This statement should give a description of the circumstances of the applicant, what the need is and the opinion of the Case Worker. Please use an additional sheet, if necessary.
Case Workers Signature _____________________________Mr/Mrs/Miss/Mrs/Other___________ Name (PLEASE PRINT) _______________________________________ Address ____________________________________________________________ ____________________________________________________ Postcode Email Address _______________________________________________________ Branch ______________________________Telephone ______________________ Date _________________________
Declaration
I declare that the information that I have given on this form is correct
to the best of my knowledge.
I agree that the information supplied on this form may be shared with
voluntary or charitable organisations and relevant statutory agencies
for the purpose of furthering my application for assistance.
The person whose details are being requested is deceased, or unable
to sign, evidence of which is enclosed (See notes below).
The person whose details are being requested in order to process the
application is unable to sign for the following reason (See notes below).
Signature of Client: Date:
Lasting Power of Attorney for health and welfare attached
Lasting Power of Attorney for financial affairs attached
In line with Information Law personal information regarding a client cannot be
disclosed without their consent. However, there are cases where the Serving/ex-Service
person is unable to sign. In such cases, further information should be supplied to the
relevant service verification office in order to confirm service. The following cases illustrate
what information should be provided:
Where the ex-Service person has died, the verification form should be accompanied
either by a death certificate, or proof of death i.e. invoice from undertaker or
confirmation of bereavement allowance or widows pension.
In cases where the Serving/ex-Service person is infirm or physically unable to sign, a
copy of power of attorney and the attorney’s consent should be provided.
Where there is no power of attorney a note from a medical professional explaining
the client’s incapacity will suffice.
In cases of estrangement, where the Serving/ex-Service person has not signed, and
as much information as possible is provided-the Service Verification offices will be
able to confirm or deny service, but in line with Information Law, no further
details can be released. 6
Signature ______________________________________________________________________
Print name _______________________ Relationship______________________Date________
7
Section II
Applicant’s Health Self Assessment Print Name (first and surname ) ________________________________ Have you ever been diagnosed with any specific medical conditions or ongoing difficulties with :
Alzheimer’s Disease (Carers please fill in section “About Me”)
Arthritis/ Joint Replacements/ Fractures
Asthma
Bowel Disease
Dementia (Carers please fill in section “About Me”)
Depression
Diabetes
Epilepsy
Heart Disease
High Blood pressure
Kidney Problems
Neurological Disorders
Obsessive Compulsive Disorder
Parkinson’s Disease
PTSD
Recent Surgery
Respiratory Disease
Skin Conditions
Stroke/TIA’s
Urinary Tract Infections
Other (please name) ______________________________
Wound Care
I have no
dressings
Please advise if you have any wounds or ulcers that will require attention during your stay.
Yes I have dressings: Where? ………………………………………………..
They require changing : When? ……………………………………………..
OFFICE USE ONLY GCASE Number
8
Personal care
Do you have professional carers visiting you at home? (Tick one box) If yes, how many times each day? Please state number of times.
I do not currently have any support at home.
I have part time family member or friend who helps me at home. ------ times a day
I have a family member or a part time carer who helps with my personal care and other issues around the home. -------times a day
I have a live in family member or full time carer or I currently live in a care home and am supported 24 hours a day. -------- times a day
Washing and Bathing (Tick one box)
I can bathe independently. Go to the next question
I can shower independently but require assistance for a bath.
I require the assistance of one carer to maintain my personal hygiene.
I require the assistance of 2 carers to maintain my personal hygiene.
Dressing (Tick one box)
I can dress independently. Go to the next question
I need support with zips, buttons and hosiery.
I require the assistance of one carer to help me dress
I require the assistance of 2 carers to help me dress.
The support I need with things like dressing, washing and teeth cleaning is …....………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………
9
Toileting (Tick one box)
I am independent Go to the next question
I am independent with a toilet frame or raised seat. Go to the next question
I require the assistance of a carer.
I require the assistance of two carers and a commode at night.
Continence (Tick one box)
I am continent Go to the next question
I use pads to maintain my independence. Go to the next question
I am incontinent of urine and require assistance from a carer and continence aids.
I am doubly incontinent and require full assistance from two carers.
How I use the toilet when I am well e.g. continence aids and getting to the toilet …....………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
Additional Information
Protection to bed
Pads used
Catheter
Stoma Bag
Weight
Under 12 stone
12 to 15 stone
15 – 20 stone
Over 20 stone
10
Eating & Drinking
Do you have any special dietary requirements? Yes No
If yes please tick relevant box
Diabetic
Yes
Gluten Free
Yes
Low Fat
Yes
Other (Describe)
Please attach your diet sheet Now please tick yes to one of the following
I can eat and drink independently.
Yes
Providing food is cut up I can eat and drink independently.
Yes
Providing food is liquidized I can eat and drink independently.
Yes
I require some assistance with eating and drinking.
Yes
I require supervision at all times while I am eating and drinking.
Yes
Do you have any food allergies? If yes please write them here
Choking
If there is a risk you may choke please give details of your management plan and seating & posture
11
Medication
I do not take any medication
I do take medication and I am able to self medicate
I will need reminding to take my medication but I am able to give it to myself
My medication needs to be given to me by my carers
One tablet at a time On a spoon
Via a syringe I need help to make sure I have swallowed
Have you been prescribed any of the following drugs in the last two years?
Sedatives/Tranquilisers e.g. Trazidone , Diazepam , Lorazepam , Estazolam Yes No
Anti-psychotic drugs e.g. Chlorpromazine Amisulpride , Haloperidol, Pimozide,
Trifluoperazine Sulpiride Clozapine Olanzapine Quetiapine, Risperidone
Remember to bring with you
An up to date repeat prescription
All your medication in a pharmacists blister pack or original packaging
Please attach a copy of your most recent prescription.
Allergies to medications
Name the medication
Reaction You Had
Anti-Coagulant please name below
Yes No
Yes No
12
Mobility
Please bring your own walking frame/rollator. We are unable to provide these for you
I have no mobility issues. I am mobile both indoors and outdoors without assistance.
Go to the next question
I am mobile with the use of an aid indoors and am able to sit and stand independently. Please indicate type of aid in box below headed additional information
I am mobile with an aid but require assistance in getting up and sitting down and transferring. Please indicate type of aid in box below headed additional information.
I have no mobility without carer and assistance. Please indicate type of aid in box below headed additional information.
Are you able to use stairs? Yes No
Are you a wheelchair user? Yes No
Is your wheelchair electric? Yes No
Do you require an electric mobility scooter if available? Yes No
Do you require wheelchair if available? Yes No
Additional Information e.g. What equipment do you use in your home?
Walking
stick
Crutches Zimmer
Frame
Wheeled Frame
Profiling
or Hospital Bed
Standing Hoist Full Body
Hoist
Turntable
History of falls (Tick one box)
No history of falls Go to the next question
I have occasional falls but I am usually able to get up unaided
I fall frequently but I am usually able to get up unaided
If I fall I need to be hoisted
13
Keeping me safe - Do I explore? Could I fall out of bed? Please consider environmental risks
Sleep Patterns (Tick one box)
I have no problems with my sleep pattern.
Go to the next question
I have occasional problems with sleeping.
I take medication to sleep well at night. I may require some reassurance.
I have trouble sleeping at night and may require support from a carer.
How I usually am – for example do I sleep a lot, am I usually very quiet?
Communication
Sight (Tick one box)
No sight
issues.
I wear glasses/contact
lenses and
require carer support
with these and help
cleaning them
I am registered
blind / partially
sighted and
require assistance
from the carers.
I am blind /
partially
sighted and use a
guide dog and will
require support
from the carers.
Hearing
(Tick one box) I have no
hearing
issues.
I have hearing aids
/issues but manage
with minimal help. I
know how to put it in
and turn it on
I have hearing aids
/ issues and need
assistance putting
it in and turning it
on
I am registered as
being deaf and
require
a large amount of
support.
14
Speech (Tick one box)
I have no
speech
issues. I can
communicate
without help.
I have speech
difficulties but
can communicate
without difficulty.
My speech is
distorted and may
require extra
support to be
understood.
I am unable to
verbally
communicate
I communicate
using aids.
Other ways I communicate if applicable – Signing, pictures or other languages? How I show how I feel. How I communicate yes and no.
Understanding (Tick one box) I have no
problems
understanding
people or
remembering
information
I have occasional
difficulty remembering
information
I have memory
loss which affects
my day-to-day
living and / or I
have been
diagnosed with
dementia in
the last two years.
I have memory loss
which affects my
ability to care for
myself and/or have
been diagnosed
with dementia
more than two
years ago.
How I show I’m in pain and how to support me
I agree that information collected as part of the application process may be retained so that any future applications may be speedily processed, and that data generated may be used for follow up assistance, statistical and research purposes. I confirm that the information I have provided in the above assessment is a true indication of my care needs. I give permission for The Royal Air Force Benevolent Fund to contact my GP or any other Health Care Professional if there are any concerns relating to the information I have given.
Signature …………………………………………………………………
Print Name ……………………………………………………..
Date………………………………………………
15
About Me ONLY FILL THIS SECTION IF YOU TICKED “been diagnosed with Alzheimer’s Disease or Dementia” on page 7 Are you prone to infection? Yes No
If yes, Urine Chest Other___________________________________________
In the event of an infection have you ever
Become verbally aggressive? Yes No
Become paranoid (suspicious of people around you)? Yes No
Become delusional? Yes No
Thrown or broken anything? Yes No
Hit out at person/persons? Yes No
How do you react to strange places?
Do you become anxious at any particular time of day? Yes No
If yes, when? ___________________________ How is this displayed? tick any box
Wandering Inability to sit still Constant questioning
Accusations of persecution Verbal aggression Throwing things Hitting out
16
Things that may worry or upset me (foods, activities ) – How I may show this
How to support me if I am anxious or upset
Behaviors I have that may be challenging or cause risk. What you can do to support me with my behaviors – things that help me relax
Things I like include: Music, TV, foods, activities and how I relax
17
My History- What is important that you know about my life (past and present) including previous employment
If this section is completed by a family member or carer please sign in the box below
Signature ………………………………………………………………… Date………………………………………………………………………… Relationship to applicant ……………………………………………
Declaration Data Protection Act The information provided by the applicant is given in confidence and is in line with Information Law.The Royal Air Force Benevolent Fund may share this information with third parties in order to seek/secure further funding. Thank you for taking the time to complete this form.
For more information about the RAF Benevolent Fund and its work visit www.rafbf.org
Royal Air Force Benevolent Fund, 67 Portland Place, London, W1B 1AR020 7580 8343
The RAFBF is a registered charity in England and Wales (1081009) and Scotland (SCO38109)
CobseoThe Confederation
of Service Charities
RAFBF Caseworker report 23 Sept.indd 8 23/09/2015 22:23