DARTFORD
BOROUGH COUNCIL
____________
_________________________________________________________________________
Please complete the form, save it, and email it to: supported@dartford.gov.uk
Strategic Directorate (External Services)
Dartford Housing Services
SELF-ASSESSMENT
Please complete this form fully and truthfully, as the information will be used to
assess your eligibility for accommodation with an enhanced housing management
service.
Surname: _____________________________
Forename(s): _________________________
NI no: ________________________________
Current Address:
Mr / Mrs / Ms / Miss / Dr
Other:
Date of Birth: _____________
Telephone No: ____________________
Gender: Male Female
______________________________________ Postcode: __________________________
Type of Accommodation you live in now:
Flat Maisonette House Bungalow Care Home
If a flat, what floor do you live on? ____________________________________________
Would you say you are generally healthy?
Yes No
Can you see? (With glasses, if worn)
Yes With difficulty: I am partially sighted or blind
Can you hear? (With hearing aid, if used)
Yes With difficulty: I am deaf
Do the people you talk to understand what you are saying?
No Sometimes All the time
Do you have breathing problems (are you breathless) at any time?
No Sometimes All the time
Have you had any falls in the last six months?
None One More
Are you able to get involved in all the activities you enjoy, without help?
Yes No
§
§
§
§
§
§
Do you ever feel lonely?
Never Sometimes Often
Tell us about any current medical conditions you may have:
Can you use the telephone easily?
Without help, including looking up numbers and dialling
With some help
I am unable to use the telephone
Can you manage your own money, for example pay your own bills?
Without help
With some help
Completely unable to handle money
Can you take your own medicine?
Without help (in the right doses and at the right time)
With help (if someone prepares it and reminds you)
Completely unable to take your medicine
Can you get around indoors?
Without help
With some help
I use a wheelchair
I am confined to bed
Can you climb stairs?
Without help
With help
Unable to manage stairs
Can you dress yourself?
Without help, including buttons, zips or laces
With help: I can do some things on my own
I am completely unable to dress myself
Can you feed yourself?
Without help
With help, such as cutting food up or spreading butter
I am unable to feed myself
B
Can you manage your personal appearance, such as washing your hair or shaving?
Without help
I am unable to manage without help
Can you use the toilet, bath or shower?
Without help
I need help to use the bath or shower
I need help using the toilet
Are you incontinent?
No
Yes, occasional accidents
Frequent accidents
Need help with a urinary catheter or enema
Do you now, or have you ever, had problems with alcohol or drugs?
Yes No
If yes, please give details:
Do you suffer from depression?
Yes No
If yes, please give details, including the diagnosis if you have one:
_________________________________________________________________________
Do you feel safe inside your home?
No
Yes
Do you have anyone who helps you when you are not well or have an emergency?
Yes
No
If yes, who is this?
Do your family, friends or neighbours support you?
No
Yes
Can you access public services such as Post Office, doctor, dentist etc?
Without help
With help
Unable to get there on my own
Are you getting any of these services?
Home Care
District or Macmillan Nurse Health Visitor
Delivered meals
Do you have any aids or adaptations in your present accommodation?
No
Yes
Do you attend a day centre, hospital or have respite care?
Yes
No
Why do you feel that you need this type of accommodation?
DECLARATION
I understand this form will be used to assess my need for an enhanced housing
management service. Any subsequent offer will be made in accordance with the
Council’s Choice Based Lettings Policy. I confirm that the particulars given in
this form are true and correct and I undertake to notify the Council of any
changes in my circumstances as soon as I become aware of them.
Applicant’s Name………………………………………………….Date………………………
For office use only
Assessment of need for enhanced services:
Result (please select:)
Meets criteria
Does not meet criteria
Risk assessment for staff and tenants:
Result (please select):
Low Risk
Medium Risk High Risk
Assessor’s Name.................................................................................................................
Date................................................................................................……………………….…..
Please complete the form, save it, and email it to: supported@dartford.gov.uk
or return to:
Dartford Borough Council, Civic Centre, Home Gardens, Dartford, Kent DA1 1DR
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