Nottingham City Signposting Service
Nottingham City Signposting Service
CLIENT CHECKLIST FORM
Title / Last Name / First Name / Date of Birth / M/F/TransGender:
Address
Postcode / Tel No.
Mobile.
No phone available / Ethnicity
First Language (please state)
Communication Needs (please state)
How many occupants are there in the house?
Housing:
Owner Occupier Rented Accommodation Shared Ownership
PLEASE SPECIFY HOUSING PROVIDER
Pathway
1. Do you have any large repairs or improvements that need doing to the home that you are unable to arrange yourself? (Including heating & electrics)
Please specify repairs/improvements: / YES / NO / Age UK Home Safety and Improvement Service (HSI)
Nottingham City
Homes
2. Do you need help totackle:Gardening (grass cutting, garden maintenance, hedge trimming, tidy ups).Odd jobs (fitting locks, putting blinds up, fitting shelves, mending fences). Decorating Please list needs: / YES / NO / Click Nottingham
(Chargeable)
3. Would you like support on how to reduce heat loss & save energy in your home? (tick all that apply) Free cavity insulation
Free loft insulation Energy switching support
Free energy saving Products Free home energy check / YES / NO / Greater Nott’m Healthy Housing Service /
Age UK HSI
4a. Do you need minor adaptations (e.g. grab rails) because you are worried about falling?
4b. Do you need any adaptations or equipment as a result of a disability?
If YES, please complete GP details overleaf and specify nature of disability:
4c.Do you need advice to purchase suitable equipment to help you lead an independent life? / YES / NO / Occupational Therapy/PAD/
Adaptations/
Disabilities Living Centre if able to afford to fund own equipment
YES / NO
YES / NO
5. Have you had a recent trip or fall, or do you feel you are at risk of falling?
If YES, please complete GP details overleaf. / YES / NO / Falls & Bone Health/CRT
6. Do you require a care alarm or other Telecare equipment to promote your independence and provide reassurance? / YES / NO / Telecare
7a. Have you got a working smoke alarm on each level of your house including the attic and cellar?
(Visit will also include a home safety check.)
If NO, is client HIGH priority or LOW priority?
7b. Would you like afree Home Safety and Security Check? / YES / NO / Home Safety and Improvement Service
YES / NO
8. Have you had a problem with rogue traders or scams and would you like advice on how to protect yourself from them? Please specify: / YES / NO / Trading Standards
9. Would you like advice on welfare benefits you may be entitled to? Please specify benefit: / YES / NO / DWP
10. Do you have any financial matters you would like impartial advice on? E.g. borrowing, savings, pensions and insurance.
Please specify: / YES / NO / Money Advice Service
11. Would you like advice on different types of accommodation that may be available? / YES / NO / Nottingham City Homes
12. Would you like information on free physical activity sessions to decrease the risk of Cardiovascular Disease. – a 12 week programme for Raised BMI, High Blood Pressure, Cholesterol, Stroke, Chronic Obstructive Pulmonary Disease, Obesity, Anxiety or Depression? / YES / NO / YMCA
13. Would you likeinformation on leisure activities, support or practical advice in relation to visual impairment? / YES / NO / My Sight Nottinghamshire
14. Would you like to make new friends, access social activities or learning? Customers will need to make their own way to venues as transport is not provided. If you are housebound and would need support to obtain a personal budget / personal assistant, then please see question 15b. / YES / NO / Age UK Kindred Spirits /
Click Nottingham
15a. Do you have any other support needs and no friend or relative to help you with these?
List support needs: / YES / NO / Sixty Plus Service
15b. Do you need a support worker to liaise with the other agencies? / YES / NO / Sixty Plus Service
16. Would you like support to stop smoking? / YES / NO / New Leaf Stop Smoking Service
Are you hearing impaired / H Housebound
17. Do you use a Nebuliser Heart & Lung Machine Home Kidney Dialysis Ventilator Oxygen Machine Stairlift Bath Hoist Are you Blind or Sight Impaired Deaf or Hearing impaired Speech Impaired Have Restricted Mobility Dementia Do you have a Learning Disability Other reason why electricity is essential
Please identify which applies by ticking the box and for other please state reason:
Alternative phone number relative, friend or mobile: / Priority Services Register
Western Power Distribution
Please state relationship or mobile:
18. Would you or someone you care for like to be supported in living with Dementia? Please refer to the Client information on page 2 of the Client information. / YES / NO / The Alzheimer’s
Society
Please complete GP details for question 4b, question 5 and question 14, if applicable:
GP name Tel:
Postcode
Any Other Comments? (including any health and safety issues)
Contact referrer prior to your visit.
Name of person completing form:
PRINT NAME / Organisation:
Phone No:
Signature / Date Form Completed
This form is designed to help you access services that you need. Your consent is needed to contact the agencies identified. Information provided on this form will be held securely on the Nottingham City Signposting Service Database. Under the Data Protection Act 1998 you have the right to access this information. Under this act information on this form may be shared with partner organisations involved with the Signposting Service to help you access further services.
I agree to referrals being made to the partner agencies involved with the Signposting Service and agree to you keeping my details on your databases and passing on any relevant outcomes to those partner agencies so that they can contact me.
Signature: Date:
(Advisor can sign with client’s permission)
OR
I wish to decline these services, but agree to you keeping my details on your databases:
Signature: Date:
Please return completed form to: Sixty Plus Service, Metropolitan, Raleigh House,
68-84 Alfreton Road, Nottingham, NG7 3NN
Or fax: 02035355204. Or email form to:
Nottingham City Signposting Service
CLIENT INFORMATION LEAFLET
The Signposting Service is a partnership between local agencies in Nottingham.
The service is designed to help you access services that you feel you might need. Following a visit today on: by
from a referral will be made to one or more of the following agencies:
Agency / Tick / When the agency telephones you, please enter the details of their visit below:Date: / Time: / Visitor’s Name:
Age UK
Home Safety and Improvement Service
Kindred Spirits
Money Advice Service
The Alzheimer’s Society
Click Nottingham
Department for Work & Pensions
Disabilities Living Centre
Falls and Bone Health Service/
Community Rehab Team
Greater Nott’m Healthy Housing Service
My Sight Nottinghamshire
New Leaf Stop Smoking Service
Nottingham City Homes: HomeLink/Repairs Contact Centre
Occupational Therapy/
Adaptations Agency
Preventative Adaptations (PAD)
Sixty Plus Support Service
Telecare
Trading Standards
Y M C A
OR: Services declined at this time
You will be telephoned within the next 28 days by the agencies above with a tick next to their name. If you or your relatives have any questions about the Signposting Service please call: 0203535 5147
Alternatively you can email:
Please remember: When callers arrive at your home always confirm it is the person you are expecting.
Age UK Notts: Home Safety and Improvement Servicewhich includes free home safety checks(FreephoneTel: 0800 888 6464), a Kindred Spirits Serviceas a Member you will have access to over 100things to do per month e.g. social activities, special interest groups, craft activities, trips or holidays. NB There are charges that may apply to this service
(Tel: 0115 841 4473)plus a Money Advice Service which offers free, impartial advice on a range of money matters(Tel: 0115 844 0011).
The Alzheimer’s Society (Tel: 0115 9343800) Their Dementia Support Workers will give expert practical advice and support to help you understand dementia, cope with the day-to-day challenges it brings, and prepare for the future. This includes helping you to access other support services, and build support networks within your community.
The Society is there for those living with Dementia either effecting them or their carer’s, the aim is to help you feel supported, and maintain independence, choice and control over your life and allow you access to Singing for the Brain events, Dementia cafes or peer support services as well as the Support Service.
Click Nottingham: (Tel: 0115 9787846) Support people to develop social connections and take up opportunities to make new friendships, learn new things and stay active. We are seeing positive outcomes in health as well as improved confidence and engagement in local community life.Handypersons ServiceNB There are charges that may apply to both of these services.
Department for Work and Pensions (DWP) (Tel: 0845 60 60 265): Offer advice on all socialsecurity benefits and state pension including - Attendance Allowance, Disability LivingAllowance , Personal Independence Payment, Carers Allowance, Pension Credit, HousingBenefit. DWP can also offer a home visiting service for those who are unable to accessservices online via or by telephone. Staff who do visit will help with thecompletion of benefit claim forms if necessary.
Disabilities Living Centre (DLC) (Tel: 0115 9855780) Provide information, advice and assessments on equipment and services for disabled people, elderly people, their carers and Professional staff. There is ample parking with some spaces available for disabled persons vehicles, level access and a disabled person’s toilet.
Falls & Bone Health Service/Community Rehab Team (Tel: 0300 300 3333, Option 5): Provide community rehabilitation to reduce the number of falls in older people. The team is made up of Nurses, Physiotherapists, Occupational Therapists, Assistant Practitioners and Rehabilitation Support Workers. People will have a full medical assessment, and a personally tailored rehabilitation and exercise programme.
Greater Nottingham Healthy Housing Service (Tel: 0115 947 2207): Provides home insulation and heating improvements for homeowners and private tenants living in Nottinghamshire. The Service is able to offer FREE loft and cavity wall insulation and grants for solid wall insulation (this is insulation for older properties and or concrete homes without a cavity). We provide the Improving Health through Warmer Homes Training Course for frontline staff, run energy saving workshops for community groups and advice on keeping warm in winter, including details about energy bill discounts. GNHHS also focuses on the promotion of the home safety and mobility services for the elderly
My Sight Nottinghamshire: (Tel: 0115 9706 806)Information on leisure activities, support and practical advice in relation to visual impairment.
New Leaf Stop Smoking Service: (Tel: 0800 561 2121)New Leaf Stop Smoking Service is the sole provider of smoking cessation support in Nottingham City.
Nottingham City Homes: HomeLink (Tel: 0845 330 3131): Manage the council stock on behalf of Nottingham City Council. Property is allocated through a choice based lettings scheme,advice is offered on housing options, plus support and guidance is provided to vulnerable applicants. Repairs Contact Centre (Tel: 0115 915 2222): available to Nottingham City Homes tenants and open 24 hours a day, every day.
Occupational Therapy (Tel: 0300 300 3333, Option 2):Provide equipment and adaptations to people with a permanent and substantial disability, to enable them to be independent in their own home. It might involve the Adaptations Agencywho provide a one-stop service to people who need to adapt their home because of a disability or due to the problems associated with increasing age.
Preventative Adaptations (PAD) (01158762485): Offer a free service to anyone aged 60 or over comprising a comprehensive range of minor adaptations to reduce the risk of falls and to increase safety in the home.
Sixty Plus Support Service (Tel: 0203 535 5150):Support with housing related issues to enable people to live safely, comfortably, and independently in their own homes. This free and confidential service provided by Metropolitan offers a range of support.
Telecare (Tel: 0115 876 3222): Combine technology and support to provide help in an emergency. It aims to help you and your carers feel more confident about living independently in your own home.
Trading Standards (Tel: 08454 04 05 06): via the Citizens Advice Bureau provides support and advice for people who have had problems with rogue traders or scams. We can also give preventative advice if you want to know how to protect yourself from these.
YMCA (Tel: 0115 948 9820): Free physical activity sessions to decrease the risk of Cardiovascular Disease - a 12 week programme for Raised BMI, High Blood Pressure, Cholesterol, Stroke, Chronic Obstructive Pulmonary Disease, Anxiety or Depression.
Priority Services Register Western Power Distribution: (Tel: 0800 6783 105)
To minimise the effect that any planned or unplanned Power cut would have on those who are reliant on Electricity for Medical or Age or Disability reasons.