For families & individuals

Home Care Initial Assessment

Thank you for choosing WellTrust. This assessment helps us understand you, your circumstances, your goals and the support you may need at home.

Your information is handled confidentially and used only to assess your care needs and contact you about your enquiry.

Section 1

About you

Tell us about the person who may receive care.

Full name *

Preferred name

Date of birth *

Gender

Address *

Postcode *

Telephone *

Email *

Preferred contact method

Preferred language

Do you require an interpreter or communication support?

YesNo

What support do you require?

Section 2

Who is making this enquiry?

This helps us understand who we are speaking with.

I am:

Name

Relationship to the person

Telephone

Section 3

What support are you looking for?

What has prompted you to seek care at this time?

When would you like support to start?

How often may support be required?

Preferred days and times

Anything urgent we should know?

Section 4

What matters most to you?

Your goals help us focus support on what matters to you.

What would you like our support to help you achieve?

What is most important to you?

What would a good day look like for you?

What would you like to continue doing independently?

Section 5

Your health and wellbeing

Diagnosed health conditions or disabilities affecting daily life

Recent changes in your health

Have you recently been discharged from hospital?

YesNo

Please provide details

GP surgery

GP telephone

Other professionals involved in your care

Relevant professional details

Section 6

Mobility and moving around

How do you normally move around?

Mobility or moving-and-handling equipment used

Known moving-and-handling risks

Section 7

Personal care

Please indicate the level of support currently required.

Area	Independent	Prompting	Some support	Full support

Personal preferences or routines we should know about

Section 8

Medication

Do you take prescribed medication?

YesNo

Support required with medication

Allergies or known adverse reactions

Are you prescribed any PRN (as-required) medication?

YesNo

Medication details

Medication support will be assessed separately and provided in accordance with the person's assessed needs, care plan and medication policy.

Section 9

Eating, drinking and nutrition

Do you require support with:

Food allergies or intolerances

Special diet

Swallowing difficulties?

YesNo

Under a dietitian or speech and language therapist?

YesNo

Section 10

Continence

Support required with continence

Continence products or equipment currently used

Bladder or bowel management concerns

Section 11

Mental health, cognition and communication

Do you experience difficulties with:

Relevant diagnosis

How do you prefer staff to communicate with you?

Triggers, behaviours, routines or helpful approaches

Section 12

Capacity, choice and decision-making

Are you able to make your own decisions about care and support?

Is there a Lasting Power of Attorney in place?

Who would you like involved in care decisions?

Communication or accessibility adjustments required

Section 13

Home environment

Type of accommodation

Who lives with you?

Are there any pets?

Stairs within or outside the property?

Known risks within the home

Equipment or adaptations at home

Other home environment details

Section 14

Safety and safeguarding

Concerns about safety or wellbeing at home?

YesNo

Concerns about abuse, neglect, exploitation or someone taking advantage?

YesNoPrefer to discuss privately

Anything that could place you, another person or staff at immediate risk?

Emergency contact

Name

Relationship

Telephone

Section 15

Social life, independence and community

What activities are important to you?

Do you require support to:

Cultural, religious or personal preferences to respect

Section 16

Family and informal support

Do family, friends or unpaid carers currently support you?

YesNo

Who provides this support?

What support do they provide?

Concerns about the sustainability of current arrangements

Section 17

Your preferred care team

Preferences regarding care workers

Other preferences or requirements

Would you prefer regular, familiar carers wherever possible?

YesNo preference

Section 18

Funding and care arrangements

How will your care be funded?

Do you already have a care and support plan or needs assessment?

Funding authority or case worker details

Section 19

Your preferred care package

What type of support are you looking for?

Preferred visit times

Approximate visits per day or week

Preferred start date

Section 20

Additional information

Is there anything else you would like us to know?Tell us anything that would help our team understand you as a person and respect your preferences, routines and independence.

Section 21

Consent

Please review the statements below before submitting your enquiry.

I confirm that the information provided is accurate to the best of my knowledge.

I understand that WellTrust Healthstaff Ltd may use and share relevant information with appropriate people or organisations involved in arranging or delivering care, where lawful and necessary.

I understand that completing this form does not guarantee care provision and that a full assessment may be required.

I consent to WellTrust contacting me regarding my care enquiry. *

Yes, I consentNo

Name *

Date *

What happens next: A member of our care team will review your information and contact you to discuss the next step. Any staff-only risk screening is completed securely after submission.

Submit your care assessment?

Please confirm that you are ready to securely send this initial assessment to the WellTrust care team.

You can cancel and continue editing without losing any information.

Assessment received

Thank you for telling us about your care needs

Our care team will review your information and contact you to discuss the right support. There is no obligation.

Reference: Care request received

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