Contact Information
Name
Address Line 1
Address Line 2
City
Postcode
Email address
Telephone Number
Date of birth
Age
National Insurance Number
Do you currently receive a service from Social
Services?
Current Benefits I currently receive the following benefits:
Disability Living Allowance (DLA)
Mobility Allowance
Attendance Allowance
Other
Benefits
(if someone receives it on your behalf) Independent
Living Fund (ILF)
I have the following extra weekly
expenses because of my frailty, disability or support needs (please give
examples. E.g. privately
arranged care, extra heating costs or maintenance of equipment.
What type of accommodation
do you live in? ( e.g.
sheltered accommodation, supported living, mortgaged/owned home)
Is
there any reason why you need to change your living situation?
Yes
Do you hold
a tenancy for your home Yes
No
Do you
have a written agreement setting out your rights and responsibilities
within your accommodation? Yes
Do you own any other
property or land? Yes
Do you currently have
savings over £18,000 Yes
Do you currently have
savings over £20,000 Yes
Do you have or need any minor aids or
adaptations to your home? (e.g. grab rails etc) Yes
Do you have or need any major aids or
adaptations to your home? (e.g. stair lift, ramp etc) Yes If yes are you registered for a Disabled Facilities Grant? Yes
Do Social Services provide
anything else to help you with your daily living ? (e.g. help line) Yes
Are
you registered deaf or hearing impaired? Yes
Are
you registered blind or visually impaired? Yes
Are you a permanent wheelchair
user? Yes
Are
there occasions where you may need more than one support at any one
time? Yes
The Resource Allocation System is designed to assess how having
support needs affects your day-to-day life. It is not just about how
disabled you are but is about the life you lead at present.
Please select the statement that fits you best.
1
Meeting personal needs
This part is about
looking after myself – things like washing, dressing and personal
support needs.
I am
fully independent and
need no support with this area of my life.
I need full intimate
support to meet my personal support needs. I need this from someone
else.
I
am able to meet my personal care needs with occasional physical or
gestural and verbal support.
I am independent in this
area but need verbal prompts to do this.
Additional Information
2 Health
This part is
specifically about any health condition that I may have that could
impact on the way I live my life.
I do
not have any health conditions which affects my daily living
I have a health condition
which means that my needs can fluctuate in an unpredictable way
I do have a health
condition and need some advice about getting appropriate treatment.
I do have a health
condition and may need some help ensuring that I get appropriate
treatment for it
Due to my health condition
I need regular support with daily living tasks
Additional Information
3
Developing and Maintaining Positive Relationships
This part is about
friendships and people I know – not just my family.
I have very few
relationships maybe only one or two – but not enough for me. I need
support to make relationships – and keep them.
I’ve got a lot of
relationships – the right number for me. I need a bit of support to
keep them.
I am happy with the
number of relationships that I have got. I don’t need help to keep
them.
I
have some difficulty getting on with people and would like some
advice as to what I should do about this
Sometime I can have
behaviours that other people have difficulty with. I need some help to
ensure that I do not upset or annoy the people I live with or those in
the neighbourhood.
Additional Information
4
Being part of the local community
This part is about doing
things in my community – like using local shops, the library, going to
the cinema, clubs, community centre, place of worship, helping
neighbours, or being involved in local organisations.
I
don’t do much in my community. I need support to do more.
Sometimes – not often – I do things in my community. I need support to
do more.
I
do things I want to in my community. I need support to continue to do
these.
I
am happy with what I do in my community. I don’t need any help to do
these.
Additional information
5 Work,
learning, and keeping busy
This part is about
having a job, learning new things or keeping busy and enjoying life
(including vocational activities).
I am
happy with the things I do during the day and I don’t need any help to
keep busy.
I
am busy – with a job or learning new things or I am enjoying my spare
time. I need support to keep these going.
I
need some advice and information so I am able to take advantage of the
opportunities that exist to work, learn or keep busy in the community.
I
have a few chances to work, learn new things, or keep busy and enjoy
life. I need support to do these more.
I don’t have many
chances to work, or learn new things, or to keep busy and enjoy life.
I need some assistance to identify how I might use my time and need
encouragement to enable me to take advantage of the opportunities in
my community to work, learn or keep busy.
Additional information
6
Living
independently This section is
about the help that I may need to live independently. It may include
keeping my home clean, safe, secure, well maintained and paying the
bills, and meeting the expectations of tenants or property owners.
I am
able to live independently in my home without support in this area.
I
need some advice about how to live independently in my home but do not
need ongoing support.
I
need help to learn the skills to enable me be able to live
independently in my home.
I
need support, advice or prompting from time to time to stay
independent in my own home.
I do not need help in this
area as there is someone
else who takes responsibility for this in my home.
Additional Information
7
Managing
money This section is
about the help that I may need to manage my money
I
don’t have any difficulties in managing my money and do not need any
support in this area.
I
need some advice and information so I am able to sort out my finances.
I
need help from someone to show me how to look after my money but I
will be able to do this myself afterwards.
I
need support or advice from time to time to help me avoid getting into
financial difficulties.
I
do not do this myself, I need someone else to do this for me e.g.
appointee.
Additional Information
8 Work
This part is
specifically about employment.
I am
in employment and my needs at work or getting to work are met.
I
have got employment and I need help at work or to get to work.
I am
not working but may like to, eventually. I would like help deciding
the right type of job for me, preparing for or getting a job.
I am
not in employment and I know work is not for me.
Additional Information
9 Meals
and Nutrition
This part is about the
help that I may need to help me to stay healthy .
I
need support from someone else to help me to both prepare my meals and
to help me to eat and drink.
I need all of my meals
provided for me or prepared for me by someone else But I don’t need
help to eat or to drink.
I
need help with preparing meals for myself but I don’t need help to
prepare snack meals ( e.g. heating microwave meals) or need help to
eat or drink.
I do not need any help
with preparing meals or help to eat or drink.
Additional Information
10
Parenting / Caring Role
I
need support with many parenting tasks, or a lot of support in my role
as a carer.
I
need some support with parenting tasks, or some support in my role as
a carer.
I
don’t need any support with my parenting role or in my role as a
carer.
I do
not have parenting or carer responsibilities.
Additional Information
11
Home
Environment
This part is about
getting around and about in my home.
I
can’t get access to any part of my home except for one room.
I am only able to use the
downstairs rooms in my home.
I can use most of
the
rooms in my home and some of the outside of my home.
I do not have
any
problems using all of my home, both inside and out.
I cannot
get
in and out of my home independently.
Additional Information
12
Making
important decisions about life
This part is about who
decides important things in my life – things like where I live and who
supports me.
I
make all my own decisions and I fully understand the consequences.
I
make all the decisions. I just need a bit of advice or support to
make them.
I have
fluctuating capacity to
make decisions and my ability to make decisions will depend on this.
I
decide most day-to-day things. But I need support with important
decisions about my life.
Other
people make most
decisions about my life. I need support to make more decisions.
All
decisions are made on my behalf.
Additional Information
13
Time spent with support This section is about the support that I need from someone else. This
may be a paid member of staff or a friend or relative. This could be
to help me with tasks, to keep me safe or because the things that I do
may put others or me at risk.
I need
constant support both during the day and at night. I get the highest
rate of DLA Care component / Attendance Allowance.
I need
significant support
during the day but I do not need help in the night. I get mid rate DLA
Care component or Attendance Allowance (low rate).
I
need intensive support during the day but I can stay on my own for
periods of time in a familiar environment.
I need
occasional support during the day or specific support for specific
reasons and stay on my own for periods of time.
I can
go out and about without support to familiar places.
I let
people know when
I need help and can go out and about without
support.
Additional Information
14
Complex needs and risks
This part is about the
things I may do. Can the things I do be dangerous for me or other
people?
I don't
know when I am in a
situation where I can be hurt or when I can hurt others.
I can
decide when I am in a
situation where I can be hurt or when I could hurt others and I am
able to weigh up the risks and consequences for myself.
Some things I do other people find difficult. I have help to manage
this so there’s no real danger to me or other people.
In
the past I’ve done things that could hurt me or others. Or I’ve done
things that were difficult for other people. But there’s no problem
now.
I’ve never done things that could hurt me or others. I don’t need help
to stay safe.
Additional Information
15
Family carer and social support
This part is about the
help I have and the help I need
Tick one box from column A and one box from column B
A
B
1
I am able to get nearly
all the help I need from adult family and friends.
I currently need no paid
support.
2
I am able to get most of
the help I need from adult family and friends.
I have or need Some
occasional paid help (e.g. less than 10 hrs support per week and 1
daily visit)
3
I am able to get only
some of the help I need from adult family and friends.
I need significant paid
support.
4
I can get little or no
help at all from adult family or friends.
I currently have 24 hour
/ 7 days per week paid support.
Additional Information
16
Family carer and social support My family carer
This part is for my
family carer. What does supporting me mean for my family carer? What
is their life like? To the family
carer :
My
caring role has a critical impact on my lifestyle - including a
significant impact on my health and well-being. I am unwilling or
unable to continue in the role as it currently is.
My
caring role has a substantial impact on my lifestyle. Playing this
role has led to high levels of stress and some health problems. I am
willing to continue in my role as a Carer.
I have some difficulty
and stress in carrying out my day-to-day caring tasks. There is some
impact on my lifestyle and playing this role leads to minor stress. I
am willing to
continue in my role as a Carer.
I am
able and willing to
continue in my current caring role. My caring responsibilities have
only a small impact
on my
daily life.
I am
able and willing to
continue in my current caring role. My caring responsibilities have no
negative impact
on my
daily life.
I
Currently do not have anyone who is my unpaid carer.
Additional Information
Is there any
other additional information that you would like to add?
Name of person supporting you to complete the form.
