HTC Self funder application e-copy- April 2012
careline/telecare application Form (self funder)
Please Note: ifyou would like to check whether you are eligible for social care funding for a Careline alarm or other telecare equipment, you should contact Havering Direct on 01708 432000 before completing this form so that they can assess your needs. If eligible, you will be referred directly by a social worker or health professional and will not need to complete this form.
Only complete this form to apply for Havering Telecare Centre services including Careline alarm and other telecare equipment as a self payer.
If you have any queries or need more information please phone 01708 756047 or email and a member of the Telecare Team will be happy to help.
Name / Date of birth
Address / Home phone
Mobile
Property / (house, flat etc) / Key safe? / Yes No
Tenure / Owner occupier / Council tenant / Private tenant / Living with family
Occupants / Lives alone / with husband/wife / with family/friends / Shared house
Tel supplier / What company supplies your landline?
Ethnicity / selectasian/brit bangladeshiasian/brit indianasian/brit pakistaniasian/brit chineseasian/brit otherblack/brit africanblack/brit carribeanblack/brit othermixed white/asianmixed white/black africmixed white/black caribmixed otherwhite/britishwhite/irishwhite/otherOther ethnic/ArabOther ethnic groupOther / Religion / selectNoneAtheistBuddhistChristianHinduJewishMuslimSikhOtherNo answer / Preferred language
If joint application for wife, husband or partner / state their name here
Care services received – if you receive carer visits please give details here of number of visits per day etc
Do you experience any of the following conditions listed below?(please )
Poor mobility Yes No / Poor dexterity Yes No
Impaired hearing Yes No / Impaired vision Yes No
Problems communicating Yes No / Cognitive impairment Yes No
Please give brief details here of any medical conditions relevant to your application. It would also help us to know your reason for applying for Careline or telecare equipment:
What telecare services are you interested in? Note this list represents only our most frequently requested equipment, if you are unsure please leave blank and we will discuss the options with you.
Careline alarm and pendant / Monitored smoke detector
Bogus caller alarm button / Monitored flood detector
Monitored medication reminder / Monitored carbon monoxide detector
Memo minder (audio message prompt) / Other (please state).
Client’s Contacts
Please add details below of your GP and also any next of kin, family or friends that have agreed to act as ‘emergency contacts’ (if none are available please leave blank).
GP Name / GP Phone
Address
GP Email
Next of Kin / titleMsMrsMrDr / Relationship
Address / Home phone
Mobile
Contact 2 / titleMsMrsMrDr / Relationship
Address / Home phone
Mobile
Contact 3 / titleMsMrsMrDr / Relationship
Address / Home phone
Mobile
How did you hear about Havering Telecare Centre services?
Advert/Leaflet / Social worker/OT / Family/friends / Other
Who should we contact to discuss this application?
Details of person completing this application
Name / If not applicant state relationship
Signature / Date
Thank you for completing this form, please return it to:
Royal Jubilee Court, Elizabeth House, 45-47 Main Road, RomfordRM2 5AW
or email to
We will contact you shortly by phone to discuss your application.
havering telecare centre use only
Date referral received by HTC
Jontek ID / R/Q / R/Q by
Install date / Install time / Install by
Equipment installed / comments