Online Assessment
Online Assessment

We have designed the Online Care Assessment Form to simply the process of assessing your needs. Once completed the information you have entered will be reviewed by a member of our Assessments who will contact you to discuss your requirements further.

Any information that you provide will only be used for the purposes of assessing your care needs. All information is securely processing and stored in accordance with the Data Protection Act and Rainbow Direct Care Privacy Policy.

All fields marked with (*) are mandatory and should be completed. Alternatively you can arrange for us to visit you and carry out the assessment in person or we can conduct a telephone assessment.

Personal Details

Title*: Other:
Forename(s)*: Surname*:
Gender*: MaleFemale Date of Birth (DD/MM/YYYY)*:
Religion: Ethnicity:

Contact Details

House Number/House Name*: Street Name*:
Town/City*: County*:
Postcode*: Contact Number*:
Other Telephone Number: Email Address*:

GP Details

GP Surgery: Name of GP:
GP Telephone: GP Address:

Self Assessment

The following sections of this Self Assessment will assist us in determining the correct level of support you may require to meet your needs. Please complete as many of the following questions as possible and use each text area if you wish to provide us with further information.

Do you require help preparing meals? YesNo
Do you require help with laundry? YesNo
Do you require help washing/bathing? YesNo
Do you require help putting/taking off clothing? YesNo
Do you require help shaving? YesNo
Using The Toliet
Do you require help using the toilet? YesNo
Do you require help cleaning the house? YesNo
Do you require help with your shopping? YesNo
Do you require help travelling? YesNo
Do you require help with paying bills? YesNo
Do you require help with benefits? YesNo
Do you require help with housing? YesNo
Gas/Electricity and Water
Do you require help with Gas, Electicity and Water? YesNo
Do you require help with Chiropody/Podiatry? YesNo
Dental Health
Do you require help with your dental/oral health? YesNo
Do you consider yourself disabled? YesNo
Mental Health
Do you have any mental health problems? YesNo
Mobility Indoors
Do you require help moving inside the house? YesNo
Mobility Outdoors
Do you require help moving outside of the house? YesNo
Do you require help with taking your medication? YesNo
Do you any difficulties with your sight? YesNo
Do you have any difficulties with your hearing? YesNo
Do you have any difficulties with your speech? YesNo
Do you require help with reading? YesNo
Do you have any trouble sleeping at night? YesNo
Do you have problems remembering things? YesNo
Do you have any concerns about safety and security in
your home?
Do you have any issues about neighbours, Anti Social
Behaviour, Parking, Bins etc?
Do you require help with driving you car? YesNo
Do you require someone to accomapny you to places like
shops, movies, church or pub?
Where are you currently living? Own HomeFamily/FriendsCare/Residential HomeSupported Living/HousingOther
More Information
Do you have any medical or health issues? YesNo
Do you recieve help and assistance from family members
or friends?

If there is anything further that you would like to tell to help us determine your needs, please tell us below.


Services Required

Home Care:Managed Live In Care:Respite Care:Palliative Care:Nursing Care:Learning Disabilities:Specialist Care:Companionship Care:Transition - Home From Hospital:Dementia and Alzheimer's Care:Extra Care - Supported Living:


Are you happy for us to contact you to discuss about your needs further?


What Happens Next

A member of our Assessment team will review the information you have provided and get back to you to discuss your requirements further.