Is this form for me?

This form is only for adult care services and equipment. For children's care services call 0845 050 7666.

You can refer yourself for a needs assessment or you can be referred by someone else such a friend, relative, doctor or social worker. Find out more about needs assessment

Whether you are a member of the public or a care professional, please complete the form below. 

Completing the form 

Please complete as much of the form as possible and click 'Submit'. Don't worry if you can't fill in parts - a member of staff will telephone to go through any missing information. Please note: you will need Adobe Reader version 7 or above to complete the form. You can find the latest version on the Adobe website.

1. Save the assessment form (pdf format, 680 KB) or assessment form (doc format, 347 KB) to your PC by right-clicking the link and choosing "save target as" or "save link as" depending on your browser. It is very important that you save the form to your computer or you will lose data.

2. Open the PDF form up, complete it and save your changes.

3. Use the form below to upload the document.