STRICTLY CONFIDENTIAL
Registered Company No. 07634770 / Service Application Form
Date of Request:
Client Details
Name / Title (Mr, Miss, Mrs)
Date of Birth / Ethnicity
Address
Post Code
Telephone No. / Mobile
E-Mail Address
National Insurance No.
Carer / Next of Kin / Tel:
Referrer
GP ‘ Name
Surgery
Telephone
Other Agencies involved
Allocated Care Manager / Social Worker / OT etc.
Type of Property / Owned Private Rented Council Flat or Rented Shared Other
Vital Information
Client’s Physical Health
Client’s Mental Health
Other Conditions
Benefits / Pensions Details
Name / Amount £ / How often / Comment
Employment Details
Name of Employer
Occupation
Start Date / Number of hours per week:
PERSONAL BUDGET
Personal Budget Option (please tick applicable boxes) / Council Managed Services (Traditional Services)
Direct Payment
Indirect Payment or Individual Service Fund (ISF)
Type of services Requested (please tick applicable boxes) / Direct Payment Management / Live-in Carer
Individual Service Fund (ISF) / Short Break Respite
Personal Care / Transport
Supported Living / Sitting Service
Day Opportunities / Activities / Employment Support
Household / Domestic Tasks / Other (please specify below)
Type of Service
Number of Allocated Support Hours
Estimated Service Start Date
Other Service Specification
Service Information / Have you received a copy of our Service Information Leaflet?
Yes No
(Tick or Double-Click the appropriate box and click “Checked” if appropriate)
Client’s Signature (if applicable at this stage) / Date
Referrer’s Signature / Date
Thank you for completing this form. A member of the Service Team will contact the client and/or referrer within 1 working day of receiving this form to acknowledge receipt and arrange one free initial consultation meeting; duration up to 2 hours. Depending on outcome of initial meeting, we will meet with the client within 5 working days to carry out a comprehensive needs and risks assessments (if applicable). If we are not able to do this we will contact the client to arrange an alternative date.
Please return this form to New Support Solutions either by post to:The Administrator, New Support Solutions, The RISC, 35-39 London Street, Reading, Berkshire. RG1 4PS
Telephone 01189 332286 Fax: 01189 332286 E-mail to:
Right to cancel
If you wish to entirely terminate the service, simply write to us at the address above giving 1 month’s notice.
We operate a flexible service and require 24 hour notice if you will not be available for support. The customer is allowed to save the unused support hours for use at a future date but not exceeding 3 months. If 24 hour notice is not received, the customer will be charged in full for support worker visit.
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