First Name *

Last Name *

Phone *

Email *

Who is the care needed for? *

Select an option

Name of person requiring care *

Street Address

City

County

Postal Code

Age of client

Gender of client

Select an option

Preferred Gender of Carer

Select an option

Information about client that will help with finding the right care

Medical Conditions

Does the client have any Medical Conditions

Arthritis

Alzheimers

Atrial Fibrillation

Autism

Anxiety

Cancer

Communication difficulties

COPD

Cerebal Palsy

Deafness

Dementia

Depression

Diabetes

Down Syndrome

Epilepsy

Fibromyalgia

Heart Disease

Incontinence

Learning Difficulty

ME (chronic fatigue syndrome)

Multiple Sclerosis

Osteoparosis

Physical disability

Parkinsons

Quadriplegia

Stroke

Visual Impairment

Other - please add to info above

Care Needs

Are they safe to be left unattended

Yes

No

Do they have mobility issues

Yes

No

If yes, what aids do they use

Does client require help with medication

No

Yes - Administration

Yes - Reminders

Care Required

Administration – filing etc

Accessing local community

Catheter Care

Cleaning/Housework

Cooking/support with eating

Companionship

Enablement

Exercising

Financial support

Incontinence Care

Medication/creams administration

Ordering/collecting prescriptions

Moving and Handling

Personal Care

Pet Care

Shopping

Transport

Any other details of care requirments

Is there any specific care experience you wish your carer to have?

Do you want the carer to have Covid vaccinations?

Yes

No

Do you have any pets?

Yes

No

What interests does the client have? What would you like to get out of the care and support?

How is the care to be financed?

Select an option

Please give details

Type of Companionship/Care needed

Day and evening visits

Sleeping nights

Option 3Waking nights

Live-in care

By checking this box, I consent to receive communications from Happiest at Home. You can opt out at any time.