Become a Service User

If you would like us to provide you with your personal care and support needs then simply:-

1) Agree Principal Terms

2) Complete our Service User Form

We will contact you and arrange a visit.

1) Principal Terms

This form will appoint us as your care service provider and outlines our responsibilities to you and the services we will provide. It will also place responsibilities on you to tell us about the service that you require, when it needs to change and if you are achieving the outcomes expected.

Our responsibilities to you:

1. Preparation of your care needs assessment. This will be produced within 24 hours of us receiving all the relevant information from your referrer in the case of an emergency, or within 48 hours for a non-emergency.
2. Preparation of your person centered care plan. To be produced and agreed with you within 48 hours of completion of your care needs assessment.
3. Agreement of your expected outcomes. We shall discuss and agree with you the outcomes you expect from our service with your consent.
4. Access to your home. We shall arrange visits to deliver your care service at the times you have agreed with us. You will give us 48 hours notice if your plans change.
5. Home Diary Records. We shall prepare a home diary record which we will keep at your home and you give us consent to do so.
6. Annual Service Review. We shall perform an annual service review or reviews on a more frequent basis with your consent.
7. Dealing with other professionals. We shall deal with the other professionals involved with your care if required.
8. On-going care and support advice throughout the year. We will monitor your service and make any changes where necessary with your consent.

Your responsibilities to us:

1. Access. To let us have access to your home at the times you want us to visit.
2. Inform. To inform us if your needs change.
3. Notice. To give us the required notice if you want to cancel visits or plan new ones.
4. Fees. To pay our fees in accordance with our terms.

Our Fees:

Our fees are based on an hourly rate so please call us to find out more about rates within your local area.

I acknowledge that the above correctly sets out the terms of our agreement.

2) Please complete our Service User form

Personal Details

Name:*

First Name

Surname

Date of Birth:*

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JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

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Day

Month

Year

E-mail:*

Home Telephone:

Area Code

-

Phone Number

Mobile Telephone Number:

Postal Address Details

House Number / Name:*

Address:*

Road / Street NameBorough NameCity / TownCountyPost Code

Please tell us about your medical condition

Please select all conditions that apply to you:*

Athritis

Asthma

C.O.P.D.

Cancer

Dementia

Epilepsy

Frailty

Heart Problems

Paralysis

Parkinson's

Peg Feed

Stroke

Please tell us about any other condition you may have:

What time of day would you require our services:

Morning

Lunch

Respite

Evening

Day sit

Night sit

Carer preference:

Male

Female

Don't mind

Please tell us any further information to assist in your care requirements:

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