Client Application

Apply for Care - House Keeping - Support Worker

Name *

First

Last

Date of Birth *

Street Address *

City *

ZIP / Postal Code *

Email *

Phone *

Gender *

Do you receive any form of care? (CARE ONLY) *

Do you have any family or friends providing unpaid care? (CARE ONLY) *

you language help

What type of care support are you looking for? (Tick all that apply)

What time of day do you require Care/ Cleaning Services/ Support work?

How many hours do you estimate you will need per day or week? (Please specify below)

How do you plan to fund your care?

If you are seeking local authority funding, have you had a financial assessment? *

Do you receive any benefits that may help cover care costs? (e.g., Attendance Allowance, PIP, Carer’s Allowance) *

What is your approximate level of savings/assets? (CARE ONLY)

21. Do you have any cultural, religious, or language preferences for your care? *

(If yes, please specify)

Are there any other specific needs or preferences you would like us to be aware of?