Name and Tel No of Person Completing This Form: Date

CONTACT ASSESSMENT

PERSONAL INFORMATION

NHS No:
NI no:
Date: / Office Ref:
Hospital no:
Service User Details:
Mr/Mrs/MsDoB ………..
Surname:
First name:
Preferred name:
Address (current):
Post Code:
Tel no:
Address (permanent):
Post Code:
Tel no: / GP
Name of main carer:
Address:
Post Code:
Tel no:
Is a carer’s assessment needed? Yes No
Ethnicity:
Religion:
Language/Communication needs
Is a translator/interpreter needed? Yes No / Next of Kin if different
Name:
Address:
Post Code:
Tel no:
Other Contact:
Name:
Address:
Post Code:
Tel no:
Type of Accommodation:
Ownership:
Access Issues:
Lives Alone: Yes No
If no, who else lives in household
Hospital Contact – This Admission
Hospital
Ward
Date of Admission
Date of Section 2 Notification
Estimated date of discharge / Details of other professionals involved
e.g. District Nurse
Name:
Address:
Post Code:
Tel no:
Name:
Address:
Post Code:
Tel no:
Diagnosis/medical condition

Name and Tel no. of person providing information: Date:

Name and Tel no of person completing this form: Date:

What is causing you a problem? (according to the service user)
What do you think could help? (according to the service user)
What other problems are there and what could help? (according to carers, assessor and others)
Other relevant information (past medical history, current support available, risks to self or others,)
Actions/referrals and next steps (including name and contact details of person/agency responsible for next stage)

The information about you has been collected to assess your need for social care and health services. Your information will be held securely and confidentially on a computer and on file in accordance with the principles of the Data Protection Act 1998. This information may be shared with other Health and social care professionals for the purposes of providing such services to you.

Signature:...... Print name:...... Date:

(Service User)

Signature:...... Print name:Date:

(Assessor)

Contact details: East & North Herts IntegComm Team - WelHatPhoenix HouseDunhams LaneLetchworth Garden CitySG6 1BE Tel: