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.