Your information and advice

Communication & Understanding

I am completing this self assessment;

For myself

With the support of somebody

On behalf of somebody

Is it difficult for you to explain how you are feeling ?

Yes

No

Do you have any difficulties with understanding and / or retaining information ? Do you regularly get confused, forget things, get lost or lose track of where you are in a new or unfamiliar place

Yes

No

Do you have any difficulties making decisions and / or understanding their impact ? You may wish to consider asking someone to help you complete this self assessment if you have difficulties communicating, understanding or making decisions.

Yes

No

Staying Safe

Have you had any falls recently ? Please provide details if you fall regularly, number of falls, if you know what causes your falls, any medical treatment you receive to help prevent falls or any Hospital admissions or if you have received medical attention for your falls.

Yes

No

Do you live alone ?

Yes

No

Are you worried about how others treat you ? We are asking this to help us identify any concerns you might have about how others treat you. This could be things that they say or do to you that makes you feel upset or hurt, it could be to do with your money, your property or it could be about the way they look after you or don't look after you.

Yes

No

Mental health & wellbeing

Are you worried about your mental health ?

Yes

No

Does your mental health affect your daily life ? This could include anxiety, depression, lack of sleep, poor motivation or stress

Yes

No

Savings and Investments

Some people have to pay for all or some of the care and support that they need. These questions will give you an indication as to whether you will be required to pay. A full financial assessment will be carried out by focus to establish your weekly charge. You are still entitled to a care act assessment (if appropriate) and support to plan your care even if you are paying the full cost.

Do you own your own home ( including shared ownership ) ?

Yes

No

Do you have savings, investments or other properties worth over £23,250 (combined) ?

Yes

No

Home & Living

Try and base your answers on a typical or average week, think about any support you have at the moment - imagine yourself alone in your home with nobody else there to help you

I can maintain and clean my home on my own ?

Yes

No

I can manage my day to day paperwork on my own ?

Yes

No

Food & Drink

I can shop for food / essentials on my own ?

Yes

No

I can prepare meals, drinks and snacks on my own ?

Yes

No

I can eat and drink on my own ?

Yes

No

Personal Care

I can use the toilet on my own and without help ?

Yes

No

I can wash on my own and without help ?

Yes

No

I can get dressed and undressed on my own and without help ?

Yes

No

Activities and social relationships

I can develop and maintain relationships with family / friends / others ?

Yes

No

I can go out into the community on my own and without help or supervision ?

Yes

No

Education, Training, Work & Volunteering

I am able to access and undertake education, training, work or volunteering without help ?

Yes

No

Caring for Others

Do you care for anyone else ?

Yes

No