Registered Charity no: 242560
Leicester Animal Aid Association (LAA)
Community Pet Support Scheme (CPSS) – pilot.
REFERRAL/CLIENT APPLICATION FORM
Eligibility: Residents of Blaby, Oadby and Wigston and Hinckley and Bosworth districts.
Each applicant will be assessed individually in terms of suitability & viability.
Our Offering:
- Providing older people and/or people with physical disabilities assistance to care for their companion animals in their own homes.
- A Foster Support Network (for the temporary care of owned pets).
Both offerings aim to support the human/companion animal relationship for as long as it remains mutually beneficial and will be provided free of charge*.
The services will be delivered by trained volunteers with the back-up of Leicester Animal Aid (LAA).
(Please note: Any veterinary costs will need to be met by the client unless these have been agreed in advance by the CPSS Co-ordinator).
Name: / Date of birth:Address: / Tel number – home:
Tel number - mobile:
Gender:
Ethnic origin:
*Is an interpreter needed? Yes ☐ No ☐
If yes what language: / *Please be aware that any Interpreter costs incurred would need to be covered by private funds or Local Authority resources, please indicate here how costs will be met: ………………………………………………………………………
What is the companion animal(s)?
Please include breed/age if known:
How many companion animals need the service?
Please confirm the date of the last visit to the vet for each animal:
Please outline any know medical condition for each animal:
Please indicate the Companion Animal Service you are interested in receiving:
a) Maintenance – of an existing relationship– through supporting animal ‘activities of daily living’. (This could include: assistance with feeding, regular care – cleaning, grooming, exercising, and prompting owners to ensure their companion animals have received prescribed products, visits to vet/specialised services). ☐
Max. 2 visits per week.
Is there any support in particular you are requesting?
b) Foster support network – opportunity to develop a new companion animal relationship.
(This might involve elderly animal rehoming, supported fostering, ‘senior companion animals for senior people’ and associated ‘maintenance’ services). ☐
Other – e.g. other match-up service - please specify what is needed:
Please confirm a contact name in case of emergency/next of kin:
Name:
Address:
Contact number:
Relationship to client:
GP Practice: / Email:
Named contact at GP surgery: / Tel number:
Practice address and post code:
Is there any regular social care involvement already in place at the home? E.g. Social services, Voluntary organisations, private providers etc. If Yes please outline service and frequency.
Current health/social care contacts:
Email/phone: / Name:
Additional relevant information. (e.g. Medical conditions/Risks relating to the client, companion animal or premises):
Name and contact details for ‘referral partner’ submitting this application:
Signature of client seeking service: / Date:
When completed please email to: or send to: CPSS. c/o Leicester Animal Aid, Elmwood Farm, Forest Road, Huncote, Leicestershire. LE9 3LE. Tel: 01455 888257.
What happens next?:
We aim to get back in touch with you as soon as possible to discuss how we can help.
Each client and their companion animal will also be risk assessed by the pilot co-ordinator.
If assessed as suitable for the scheme a tailored programme of support for an agreed length will be provided and the client will be asked to agree to this (see outline below). At the end of the intervention the pilot co-ordinator will evaluate the input.
*This service is provided free of charge with the exception of boarding & emergency animal care which will incur a cost.
Office use only:
Request received by LAA: CPSS / Date:Accepted/rejected for service / Date:
Feedback to client / Date:
Receipt of signed agreement to services / Date:
Recorded on LAA database (accepted applications only) / Date:
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