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Referral for Equipment & Adaptations Team

Items marked with an asterisk (*) MUST be completed

Personal Details

*Family Name:

*2. Forename:

*3. Gender:

Male Female

4. Title:

Mr Mrs Miss Ms
Other (Please Specify Here)

5. Date of Birth:

*6. Marital Status

Married Couple Single Widowed Other (Please Specify Here)

7. Language

8. Ethnic Group

*9. Address

10. Previous Address

11. Lives with (if alone, please type "Alone")

12. *Telephone Number

B. Person Making Referral

*1. Person making referral (if referral not made by client)

2. Address of person making referral

3. Relationship to client?

4. Telephone Number?

C. Present Packages

1. Any present care packages?

2. Other Services?

Part D - Property

*1. Property Type
Local Authority
Housing Association
Private (Owned)
Private (Rented)

Flat
Terraced House
Bungalow
Town House
Semi-detached house

Sheltered Housing
Communal Shower

Part E - The Client

1. Clients Perceived Needs:

*2. Details of medical condition or other factors affecting client's health

3. Are thee any days when the client is NOT available to be visited ? If yes, please list them here

*4. We may need to ask for further information from your doctor. Would you allow us to contact your GP/consultant if required?

Yes No

5. If you answererd YES to the above question, please give your GP's name and address

GP'sName

GP's Address

6. Clients Ability A= Independent B=Independent(with difficulty) C=Need help with task D= Carer Performs
IS THE CLIENT ABLE TO:	A	B	C	D	Comments
*a) Manage stairs/steps outside main entrance to property
*b)Are there any handrails at the secondary entrance ?	Yes No
*c)Manage steps/stairs inside
*d)Move around when on the same level
*e)Get in/out of bed
*f)Get on/off the chair
*g)Get in/out of bath/shower
*h)Get to the toilet
*i)Get on/off the toilet
j)Wash self
k)Dress
l)Use a knife/fork/spoon
m) Hold mug/glass
n)Prepare/cook food
o)Light and maintain the fire

7. Which of these is the most difficult for client?

8. Does client use a wheelchair indoors?

Yes No

9. Does client use a wheelchair outdoors?

Yes No

10. How does the client manage transfers ?

11. Has client made any previous applications to us?

Yes No

12. Has client made any previous application to OTs?

Yes No

13. Is there anything else you would like us to know?

Your application has been submitted