TRANSFER ASSESSMENT APPLICATION
By completing and returning this Application Form to Wessex DriveAbility you are giving consent to undertake a Transfer Assessment. Your consent may be withdrawn at any time.
Client Signature:………………………………………… Date:………………………………………………..
Print Name:………………………………………………………
It may be useful for your Doctor, Consultant or Health Professional to have a copy of your report. Please complete the details below:
Name of Doctor / Consultant / Health Professional:……………………..……………………………………..
Medical Practice Address:…………………………………………………......
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1.PERSONAL DETAILS
Mr / Mrs / Ms / Miss / Other……………
Forename/s:………………………………… Surname:………………………………..……......
Address:……………….………………..……………………………………………….…......
Postcode:…..……………………... Email address…………………………………………………
Contact number/s:……………………….….………….… Date of Birth:……….…………………
Your Height:…………………………………….Your Weight:………………….……………………
- CONSENT TO SPEAK TO A THIRD PARTY
Wessex DriveAbility will only discuss information with the applicant. However, on occasion the applicant may wish for us to discuss their details with a third party.
Should you require us to discuss your information with any other person please provide their details below:
Name: ………………………………………… Relationship: ..…………………………………….
Contact telephone number(s): ……………………………………………………………………....
Address: ..………………………………………………………………………………………………
…………………………………………………………………………....Postcode: …………………
Is there a Power of Attorney (POA) or Deputyship in place: *YES NO
*If YES please ensure that the details above in section 2, are of those who are named on your POA or Deputyship.
Who is paying for the assessment?(Please tick)
Myself / Family / Disability GroupAnother Charity / Solicitors
Motability / Others
How did you hear about us? (Please tick)
Attended before / Solicitors / Garage/AdaptorDriving Instructor / Other Mobility Centres / Publications/Media
Motability / DVLA / Forces
Friends / Relatives / Doctor / Therapists / Others
ETHNIC ORIGIN
In order to support equality as required by Public Bodies we ask that you indicate you ethnic category
White / Mixed / Asianor Asian British / Black or Black British / Chinese or other ethnic group
British / White and Black Caribbean / Indian / Caribbean / Chinese
Other White Background / White and Black African / Pakistani / African / Any other
Irish / White and Asian / Bangladeshi / Any other Black background
Any other mixed background / Any other Asian background
3. NATURE OF DISABILITY OR PROBLEM(S)
In your own words please specify your disability or problems:
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Are you currently on anymedication? *YES NO
If *YES state name………………………………………………...………………….…………..…...
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4. MOBILITY DETAILS
Are there any restrictions on how far you can walk? *YES NO
If *YES, how far can you walk?
Do you use?(Please circle)A - An electric powered scooter / wheelchair
B- Manual Wheelchair (Folding)
C- Manual Wheelchair (ridged)
If you use a wheelchair? YES NO
Can you get in / out of your wheelchair unaided? YES NO
Are you able to load your wheelchair into a vehicle without difficulty? YES NO
Do you require any aids when walking? YES NO
Do you receive High Rate Mobility Allowance? YES NO
If you receive the Higher Rate component of the Disability Living Allowance please call Motability on 0300 456 4566 and ask to be referred to Wessex DriveAbility for an assessment
5. DETAILS OF AIDS AND EQUIPMENT
If you have a scooter or wheelchair that you wish to carry with you in your vehicle, please give as many details as you can such as manufacturer, make and type.
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Please give details of any other equipment such as walking aids that you will need to take with you in your vehicle.
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6. TRANSFER ISSUES
Have you been assessed for your transfer needsbefore? YES NO
If YES, which assessment centre and when………………………………………………………….
If you currently have a vehicle that you travel in please can you give details such as manufacturer, make and number of doors and state what problems you are having with your transfers.
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What do you hope to achieve from the Assessment?…………………………..………………
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7. APPOINTMENT PREFERENCE
We will contact you to arrange an appointment in due course if not already arranged. In order to assist us, do you have any specific days / dates or times that you are NOTavailable
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By completing and returning this application form to Wessex DriveAbility, you are giving consent to undertake a Transfer Assessment. Your participation in the assessment may be rescinded at any time.
It is important that you understand and agree to the following statements by signing this declaration:
-I consent for Wessex DriveAbility to use information provided for statistical purposes only. Any information that is used by Wessex DriveAbility will be anonymised and will be treated as strictly confidential in line with General Data Protection Regulations.
-All personal data will be processed by Wessex Driveability in accordance with the General Data Protection Regulations and according with Wessex Driveability’s privacy policy and guidelines. For full details please visit our website .
-We keep your personal data only for as long as reasonably necessary for the purposes for which it was collected. After this time, it will be securely destroyed.
-We will never use your details for the purposes of marketing or promotion or sell or share your details with unrelated third parties.
-You have the right to request to see any personal data that we hold on you and to have any errors corrected. Requests to see data should be made in writing to: The Centre Manager, Wessex Driveability, Leornain House, Kent Road, Southampton, SO17 2LJ. We reserve the right to perform an identity check before releasing any personal data.
Client Signature:…………………………………………… Date:……………………………….
Print Name:……………………………………………………………
Thank you for completing the above details.
Please return the form to:
Wessex DriveAbility, Leornain House, Kent Road, Portswood, Southampton, SO17 2LJ
Please select your payment method:
£59 Cheque: Online:
(Enclosed)
(Chequesshould be made payable to ‘Wessex DriveAbility’)
If you have any questions, please contact us on: 02380 554 100
or email