Page 1 of 15 What is your name?Full name* Do you have a preferred or alternative name you would like us to use? (optional) Yes What is your preferred name?* Page 2 of 15 Where do you live?Postcode* Address*House number, Street and Town you live in Page 3 of 15 When we contact you...Select which is your preferred method?*You can pick more than one Home phone number Mobile number Email Other Home phone number* Mobile number* Email address* Other*Please let us know what other way you would like us to make contact Page 4 of 15 When we contact you...Do we need to consider any additional support when contacting or sending information to you?*For example: further support for hearing / vision / larger print / easy read Yes No Please let us know how we can help?* Page 5 of 15 When we contact you...Are you able talk to us yourself?* Yes No Who else can support you when we contact you?*Consider appropriate friends/family/Care Act independent advocate if required Page 6 of 15 Tell us about yourselfWhat is your date of birth?* MM slash DD slash YYYY What is your gender?* Male Female Unspecified What is your ethnicity?*If you would prefer not to say then please let us know Page 7 of 15 Where can we contact your GP if needed?What is your GP surgery's name and address?* Page 8 of 15 What do we want to know about you? We need to know about your current social care concerns, what matters to you now, what is important to you, and who supports you now, to help us understand the best support to meet your needs. We may work with you to: refer you to other agencies (e.g. voluntary sector agencies), provide you with information or advice, explore equipment that may assist you, or other ideas/services we can look at together. Social care describes any help you may need to live as well as possible, with any illness or disability you have. It includes help with things like: getting out of bed, washing and dressing, dietary needs (eating and drinking) getting to work, seeing friends and being part of the community caring for your family, emotional support at a time of difficulty and stress, and helping friends and family members who may be caring for you. Or something else which is impacting on your wellbeing and independence. Page 9 of 15 Your situationWhat are your main health care needs/disability/impairment?*Please tell us if you have a physical, mental, sensory or learning disability/autism need Page 10 of 15 Your situationTell us about any additional factors that impact on your wellbeing and independence?*For example: What are you finding difficult? What impacts on your daily living needs? How have you tried to support yourself so far? What ideas have you had that can help you to improve your situation? Page 11 of 15 Your situationTell us about what is important to you.*For example: tell us about what you can do and what you would like to be able to do, with support. Tell us what you value in your life, how you spend your time and what you enjoy doing. Page 12 of 15 Your situationWho supports you in your life at present and what do they support you with? Is a Carer(s) involved?*For example; a spouse/partner/family/friend/neighbour Page 13 of 15 Your situationPlease provide the names and contact details of those who support you (with their consent):Click on the + symbol after the 'Relationship to you' field if you need to add more contactsNameAddressContact numberRelationship to you Page 14 of 15 Sharing your information Keeping your information private: The answers you have given us in this form will be kept confidential, however we may need to share your information so we can help you. We will talk to you about this if needed. When we will share your information: We will only share information which is relevant and necessary. If we do, it will only be with people and organisations involved in your care such as; Devon County Council with staff members who need it to provide social care services. Organisations involved in your care and support, such as health services and private care providers. Choosing not to share your information You can choose not to share your information (please call us if you want to discuss further). If you choose not to share your information the following things may happen; we may not be able to help you meet your needs. we can provide you with information so that you can contact the relevant organisations yourself. Do you consent to us sharing your information?* Yes No Page 15 of 15 Sharing your informationIs there anyone you don’t want us to share your information with?* Yes No Please let us know who we shouldn't share your information with*CommentsThis field is for validation purposes and should be left unchanged. Δ