Adult self assessment tool


    Your details


    Who is the assessment for?


    Address


    Contact

    GP's details

    Supporting you in your assessment

    E.g. a family member or friend present

    About your caring role

    Please provide details of of the person(s) you care for:

    Caring for others

    If yes, please give their name, contact details (including address)

    Support from others

    This section asks about other people (not including the cared for) who may be dependent on you. We recognise having a caring role can affect the whole family, particularly children and young carers. We want to understand the impact your caring role has on your family so that further support can be provided if needed.

    Home and finances

    Eating healthily

    Social, relationships, activities and the community

    Work, training, education and volunteering

    Your mental health and wellbeing

    Your physical health

    Ongoing care and support

    How can we help

    Thinking about the information, you have provided above, tell us how we can help you to achieve your wishes, preferences and desired outcomes to promote and maintain your general health and wellbeing:

    Please include information such as:

    • Is there anything else that you would like to tell us that you feel is important for us to know?
    • What help and information would you like from us?
    • What areas do you want help or support with?
    • What support do you need to be able to achieve your wishes and goals?
    • What would make your life and caring role easier?
    • Are there new experiences or activities that you would like to try (e.g. work, activities or education)?

    Consent

    Thank you for taking the time to complete this assessment. The information in it will enable us to provide you with the right information, advice or support.

    We will contact you in due course to let you know the outcome of your assessment but if your situation changes in the meantime, please contact us.