NATIONAL CARE HOMES ASSOCIATION

Resident Application Form

C4 - 077

Please Note: If you need help in completing this form, please tell us and we will arrange assistance. The information you give on this form helps us to decide if we are able to meet your needs for the foreseeable future. It is important that you (or somebody who is helping you): Complete the form as fully as you can Provide accurate information Read the enclosed literature, brochure or other paperwork and understand the services we can offer. Sign the form. We will contact you, within three working days of receiving the completed form, to let you know what action we plan to take. If your answer will not fit in the space provided, please use a separate sheet.

Section 1. Personal Details

Surname:

Mr, Mrs, Miss, Ms or other title:

First name:

Date of Birth:

Preferred method of address (title, first name, nickname):

Current home address:

Postcode:

Telephone no:

When and how is the best time to contact you? (e.g. telephone in the morning, by letter, etc):

Nationality

National Insurance no:

Next of kin or the person who will deal with your affairs:  Name:

Mr, Mrs, Miss, Ms or other title:

Address:

Postcode:

Telephone no:

Relationship:

Issue no:1      Rev:0      Issue Date:.........................................       Approved by:....................

Page 1 of 3

©Bettal Quality Consultancy     Cared 4 2001

NATIONAL CARE HOMES ASSOCIATION

Resident Application Form

C4 - 077

Section 1. Personal Details (continued)

Are you related to anyone who lives or works in this home?

YES/NO

Do you have any pets that you would like to bring with you to residential care?

YES/NO

If yes, what type of pet/s?

Section 2. About your current home and your need to move into residential care

Where do live at present?

Why do you think you need to move?

Section 3. About any assistance you need  Please tick the statements that apply

I can dress / undress

I can partly dress

I find dressing difficult

I can do housework

I can manage light dusting etc.

I do not do housework

I do my own laundry

i do some laundry

I do not do laundry

I am fully mobile

I sometimes needs help.

I am not mobile

I walk unaided

I walk with a stick or frame

I use a wheelchair to get around

I am generally good health

I am not always in good health

I have ongoing medical needs

I don't take medication very often

I take medication but look after it myself

I would like help with my medication

If you do not feel able to answer these questions or would like further help with answering them, please let us know and someone will help you.

Issue no:1      Rev:0      Issue Date:.........................................       Approved by:....................

Page 2 of 3

©Bettal Quality Consultancy     Cared 4 2001

NATIONAL CARE HOMES ASSOCIATION

Resident Application Form

C4 - 077

Section 4. Declaration The information on this form is, as far as I am aware, accurate. I realise that the home can only create an effective plan of care which meets my needs if it has the necessary information available to base it upon.

Signature:........................................................................

Date:..................

or

Signed on behalf of:(please print name) ...................................................................

By:(please print name) ............................................................................................

Signature:........................................................................

Date:..................

Relationship to applicant: ..........................................................................................

Also if you could please write down the information of your Gp for our records.

Name:

.........................................................................................................

Address:

.........................................................................................................

Telephone no:

.........................................................................................................

Issue no:1      Rev:0      Issue Date:.........................................       Approved by:....................

Page 3 of 3

©Bettal Quality Consultancy     Cared 4 2001