Action Deafness (AD) Community, a Care Quality Commission (CQC) registered organisation, provides personalised one to one and personal care support to deaf, deafened, hard of hearing and deafblind (D/deaf) people through the provision of personal assistants – maintaining their independence in the community, developing skills to enable them to live independently/increasing their independence, assisting with personal care, and supporting them to access a variety of services.

1 Service User Details:

Please fill in the boxes below

MrMrsMissMsOther

(If Religion or Ethnic Origin are unknown or the person prefers not to say, please state this)

2 Next of Kin:

Give details of next of kin to be contacted in the event of an emergency:

YesNo

3 Additional Useful Contacts:

Add the names and contact details of others who are involved in assessing the care needs at present, so we are able to work together to provide the best service:

Doctor/GP

Social Worker

Name of any other organisation(s)

4 Initial Assessment:

Please complete the next section to give as full a picture as possible:

YesNoIn Process

YesNo

Managing and maintaining nutritionMaintaining personal hygieneManaging toilet needsBeing appropriately clothedBeing able to make use of the adult’s home safelyMaintaining a habitable home environmentDeveloping and maintaining family or other personal relationshipsAccessing and engaging in work, training education or volunteeringMaking use of necessary facilities or services in the local community including public transport, recreational facilities or servicesCarrying out any caring responsibilities the adult has for a child

Confidentiality Policy and Data Protection Act

AD Community is committed to providing a confidential service and have our own confidentiality policy in place which is available on request.

The personal data collected on this form will only be used for the purpose of processing the referral in accordance with our policy, i.e. for administrative reasons. In addition, statistical (but not personal) information may be shared with funding bodies and the Government for monitoring purposes.

As some of the personal data we have collected is deemed sensitive under the Data Protection Act, your written consent is required. You can provide that by signing below.

We may contact you on occasions with relevant information and may contact third parties such as your social worker, health/care workers etc., in relation to your support needs. No details will be passed to any commercial organisation.

I understand and agree to the processing of my personal data provided on this form according to the terms outlined above and confirm that all information on this form is correct.

No details will be passed to any commercial organization.

I understand and agree to the processing of my personal data provided on this form according to the terms outlined above and confirm that all information on this form is correct.