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Self directed support questionaire

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  • 1. My Help, Care and Support NeedsHow do I get the help I need? 1. Complete this form. This form is to help us find out about what you can do and what you need support with. For each question, please tick the statement in “My View” column that is closest to your needs. Then tell us what help and support you already get to meet your needs, if any. This help may be from family, friends, neighbours, equipment, voluntary services or healthcare. There is also space to help you explain what you need help with and why. 2. Carers and Workers View Sometimes others can see your needs and existing support differently. If you have a carer, they can record their views if they like. When we meet you, we will record our view and then discuss any difference in views to record a “final view” of your needs and your existing support. 3. What happens next? From your answers we can work out if you are eligible for support from us, and how much money is needed to pay for support to meet your needs. Depending on your financial situation, you may have to pay something towards your support. You will then decide how you wish to use this money to meet your eligible needs, and record these choices in your Support Plan. If you want us to, we can help you make your plan and also give you ideas about the services that you might use. Once the plan is agreed and the services are up and running, we will look to see how well those services are meeting your needs and if anything should be changed. If you are not eligible for support, we will contact you to discuss how you might be able to meet your needs in other ways.Client Name: Client ID:Date: Assessor’s name: 1
  • 2. What if I can’t complete the form?Anyone who knows you well and you trust can help you complete the form. If you havenobody to help you, or if you prefer, someone from social services will help you.Do you have any other questions?We have tried to keep this short so that there isn’t too much to read, but if you want to know,please ask. We are here to help.Confidentiality and ConsentThe information you give us is confidential, however, you need to be aware of the following: If you tell us anything that shows that you or another person is at serious risk, we cannot keep this confidential. To make sure you that you get the help, care or support you need, we might need to ask other people involved in your care for information. We also need to share some information with other people or groups who will provide you with support. We need your permission to do this.If there is anything you do not wish us to share, or anyone you do not wish us to shareinformation with, please write it here. You can change the contents of this box later if youwish.Please print your name and give a signature.Your name: Date:Signature:Or, name of person signing on your behalf(If appropriate):Client Name: Client ID:Date: Assessor’s name: 2
  • 3. 1. Choice and ControlThis is about making choices and decisions about things in your life, for example, where youlive, who assists you, what you do, and how your money is spent.Please tick the box below that best describes how you can make choices and decisions. My view Carer’s Worker’s Final view view viewa) I am able to make my own choices and decisions even though others may not always agree with what they are.b) With some assistance I am able to make all the choices and decisions about my life.c) I am able to make most day-to-day choices and decisions but need assistance to make important decisions about my life.d) Other people make most or all of the choices and decisions about my life.You can write here anything to help explain how you make choices and decisionsabout your life:Client Name: Client ID:Date: Assessor’s name: 3
  • 4. 2. CommunicationThis section is about communicating with other people, making yourself understood andunderstanding others. Ways of communication include reading, writing, speaking, gestures,signing and using support aids.Please tick the box below that best describes how you can communicate.Because of language, environment, illness or My view Carer’s Worker’s Final viewimpairment, I need assistance to communicate view viewand be understood by others…a) In some situations.b) Most of the time.c) All of the time.d) I am unable to communicate.e) I don’t need any help with this.I already get help from…(e.g. family, friends, equipment, voluntary services, healthcare)This help will give me… My view Carer’s view Worker’s view Final view1. All of the support I need.2. Most of the support I need.3. Some of the support I need.4. None of the support I need.You can write here anything which helps to explain what you need and whyClient Name: Client ID:Date: Assessor’s name: 4
  • 5. 3. Managing my practical tasks of daily livingThis is about shopping, doing your laundry, managing your money, managingcorrespondence, paying your bills, making appointments and keeping your home clean andtidy.Please tick the box below that best describes what help you need with managing yourpractical tasks of daily living.I need support with this … My view Carer’s view Worker’s view Final viewa) Monthly.b) Weekly.c) Daily.d) I don’t need help or support with this.I already get help from…(e.g. family, friends, equipment, voluntary services, healthcare)This help will give me… My view Carer’s view Worker’s view Final view1. All of the support I need.2. Most of the support I need.3. Some of the support I need.4. None of the support I need.You can write here anything which helps to explain what you need and whyClient Name: Client ID:Date: Assessor’s name: 5
  • 6. 4. Meeting my personal care needs This is about your personal care needs during the day and night; things like getting in and out of bed, personal hygiene and appearance, getting dressed, taking medication and going to the toilet. Please tick the box below that best describes what help you need with meeting your personal care needs.A) The help I need with this is… My view Carer’s Worker’s Final viewB) view view a) Reminding or encouraging a few times a week. b) Practical help once or twice a week. c) Help once or twice a day. I need the support of one person. d) Help more than twice a day. I need the support of one person. e) Help once or twice a day. I need the support of two people. f) Help more than twice a day. I need the support of two people. g) I don’t need help with this. I already get help from…(e.g. family, friends, equipment, voluntary services, healthcare) This help will give me… My view Carer’s view Worker’s view Final view 1. All of the support I need. 2. Most of the support I need. 3. Some of the support I need. 4. None of the support I need. You can write here anything which helps to explain what you need and why Client Name: Client ID: Date: Assessor’s name: 6
  • 7. 5. Eating and drinking (meeting my nutritional needs)This is about the support you need to make sure that you are able to eat and drink properly.This includes support to prepare drinks, snacks and a main meal each day and any support,prompting and encouragement or supervision you may need to eat and drink enough.I can eat by myself but need help making My view Carer’s Worker’s Final viewor getting… view viewa) A main meal only.b) Meals, snacks and drinks.I need help in both making and eating…c) A main meal only.d) All meals/ snacks and drinks.e) I need assistance with feeding, using equipment e.g. PEG feed, NG tube.f) I can make and eat meals but need reminding or encouragement.g) I don’t need help with this.I already get help from…(e.g. family, friends, equipment, voluntary services, healthcare)This help will give me…. My view Carer’s view Worker’s view Final view1. All of the support I need.2. Most of the support I need.3. Some of the support I need.4. None of the support I need.You can write here anything which helps to explain what you need and whyClient Name: Client ID:Date: Assessor’s name: 7
  • 8. 6. Getting in and around my homeThis is about getting in and around the rooms inside your home that are essential for you touse.I need help with accessing or getting around... My view Carer’s Worker’s Final view view viewa) One or more essential rooms. I need help from one person.b) One or more essential rooms. I need help from two people.c) I can get around my home by myself but am unsafe due to tripping over things or falling.d) I don’t need help with this.I already get help from…(e.g.family, friends, equipment, voluntary services, health care)This help will give me…. Your view Carer’s view Worker’s view Final view1. All of the support I need.2. Most of the support I need.3. Some of the support I need.4. None of the support I need.You can write here anything which helps to explain what you need and whyClient Name: Client ID:Date: Assessor’s name: 8
  • 9. 7. People that are important to meThis is about friends and people you know, not just your family. My view Carer’s Worker’s Final view view viewa) I am happy with the number of people that I am close to. I don’t need support to keep these relationships.b) I am happy with the number of people that I am close to. I need a bit of support to keep these relationships.c) I have nobody or very few people that I am close to. I need support to make positive relationships and keep them.d) I have difficulty getting on with people and need a lot of support to help me to make and keep positive friendships and relationships.e) I have some people around me, but I feel that they may not be positive relationships and I need some support to change things.I already get help from…(e.g. family, friends, equipment, voluntary services, healthcare)This help will give me…. Your view Carer’s view Worker’s view Final view1. All of the support I need.2. Most of the support I need.3. Some of the support I need.4. None of the support I need.You can write here anything which helps to explain what you need and whyClient Name: Client ID:Date: Assessor’s name: 9
  • 10. 8. Being part of my local communityThis is about getting out and about and doing things such as going to the local shops, thelibrary, a community day centre, a place of worship, visiting neighbours and friends, usingpublic transport, going out by yourself or being involved in local organisations. My view Carer’s Worker’s Final view view viewa) I am satisfied with what I do or don’t do in my community. I don’t need any support with this.b) I do the things I want to in my community. I need ongoing support to continue to do these.c) I would like to do more in my community. I need ongoing support to do more.d) I do very little in my community. I need ongoing support to do more.e) I would like to do things in my community, but my current situation means I can’t at the moment.I already get help from…(e.g. family, friends, equipment, voluntary services, healthcare)This help will give me… My view Carer’s view Worker’s view Final view1. All of the support I need.2. Most of the support I need.3. Some of the support I need.4. None of the support I need.You can write here anything which helps to explain what you need and whyClient Name: Client ID:Date: Assessor’s name: 10
  • 11. 9. Keeping Safe This is about how your behaviour, mental health or capacity affects the safety of yourself or other people around you.Due to my behaviour, mental health or My view Carer’s Worker’s Final viewcapacity I need help to keep myself or others view viewsafe…a) Once or twice a month.b) Once or twice a week.c) More than twice a week.d) At all times. I need help from one person.e) At all times. I need help from two people.f) Some things I do, or don’t do, am a problem for others but there is no risk to myself or others.g) There are no concerns about my needs or behaviour being a risk to the safety of others or myself.I already get help from…(e.g. family, friends, equipment, voluntary services, healthcare)This help will give me... My view Carer’s view Worker’s view Final view1. All of the support I need.2. I get most of the support I need.3. I get some of the support I need.4. I get none of the support I need.You can write here anything which helps to explain what you need and why Client Name: Client ID: Date: Assessor’s name: 11
  • 12. 10. Accessing work and learningThis is about the support that you need to access learning opportunities, or to get and keep ajob. My view Carer’s view Worker’s view Final viewa) I do not wish to work or take part in learning opportunities.b) I am busy with a job or learning new things and I am happy with this. I don’t need any support to keep this going.c) I am busy with a job or learning new things but need some support to keep this going.d) I need assistance to be able to access work or learning opportunities.e) I would like to work or take part in learning opportunities, but my current situation means that I am unable to do this at the moment.I already get help from…(e.g. family, friends, equipment, voluntary services, healthcare)This help will give me… My view Carer’s view Worker’s view Final view 1. All of the support I need2. Most of the support I need3. I get some of the support I need4. I get none of the support I needYou can write here anything which helps to explain what you need and whyClient Name: Client ID:Date: Assessor’s name: 12
  • 13. 11. Being a parentThis is about the support that you need to care for any children under the age of 18 that youare responsible for. This includes their personal care, preparing meals and ensuring theirsafety. My view Carer’s Worker’s Final view view viewa) I do not have any children under the age of 18. x x Xb) I do not need any support with caring for my children.c) I do have children under 18 but my current situation means that I am not responsible for caring for them.I need support caring for my children…d) Once or twice a day.e) 3 to 4 times a day.f) At least 5 times a day.g) All the time, both day and night.I already get help from…(e.g. family, friends, equipment, voluntary services, healthcare)This help will give me… My view Carer’s view Worker’s view Final view1. All of the support I need.2. Most of the support I need.3. Some of the support I need.4. None of the support I need.You can write here anything which helps to explain what you need and whyClient Name: Client ID:Date: Assessor’s name: 13
  • 14. 12. My CarerThe person who provides you with the most support should complete this section. Acarer is a partner, relative, friend or neighbour who chooses to help and support you, not apaid home care worker or nurse. This section looks at the effect of the support your maincarer provides to you on their life and the support your carer needs to continue to care foryou. If there is more than one carer, they will each need to complete a form. Your social careworker will provide additional forms if necessary.Did your Carer participate in this Assessment? Yes No N/A (No Carer) xWas information/advice given to your Carer? Yes No N/A (No Carer) xHow old is your Carer? Under 18 18-64 65-74 75+For your CarerIn the previous sections, you have let us know about the level of support that you areable to provide in the future and where additional support is required to help meet theneeds of the person that you care for. Please also tell us more about the support you mightneed to carry out your caring role.Throughout the year, I need… Carer’s view Worker’s viewa) No breaksb) Occasional breaks or as and when neededc) Regular breaks throughout yeard) Frequent breaks (at least weekly)A carer’s assessment helps you to tell us in more detail about any needs that you may haveas a carer, and find the support you may need to keep you in good health and balance caringwith your life, work and family commitments. Every carer is entitled to an assessment.Would you like a carer’s assessment?Yes NoClient Name: Client ID:Date: Assessor’s name: 14
  • 15. Please tell us about the support you need and how it will help you in your caringrole.Client Name: Client ID:Date: Assessor’s name: 15
  • 16. Additional information/summaryThis section can be used to tell us any other information about you, or help us summariseyour help, care and support needs.Client Name: Client ID:Date: Assessor’s name: 16
  • 17. My thoughts on this formPlease tell us what you think about this form, as this will help us to improve it. What did you likeabout it? Is there anything that could be made better? If you got this form before your social careworker came to visit you, was it useful to look at it first and start completing it? My signaturePlease print your name and sign below to tell us you agree with how this assessmenthas been filled in.Your name:Signature: Date:Social care worker name:Signature: Date:Carer’s name (if applicable):Signature: Date:Client Name: Client ID:Date: Assessor’s name: 17

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