Application andSelf Assessment Form Princess Marina House Rustington, West SussexBN16 2JG

Print Name (First, Middle Initial, Surname)

…………………………………………………………………………………….

Application Form, Self Assessment Form, Financial Assistance Request

Office Only G CASE #

1

Application Form for a Short Welfare Break

Princess Marina House, Rustington, West Sussex, BN16 2JG

01903 784044 01903788970 www.rafbf.org/princess-marina-house

This questionnaire is strictly confidential and will become part of your medical record.

Details of Service on Whom Eligibility is Based Applicant Yes No

Name (First, Middle Initial, Surname):

F

DOB: __________________

Marital status:

Single Partnered Married Separated Divorced Widowed

Maiden Name :_________________

RAF Service Number: ______________ Rank : ________________ Branch /Trade ________________ From to

War Disability Pensioner Yes No

If Deceased , Date of Death _________ New applicants only, please attach photocopy

of Death Certificate

NHS Number

Details of Eligible Applicant (if not above) Relationship to Person at Section A __________

Name (First, M.I. Surname): _____________________________M F DOB: _________

Date of Marriage _____________

NHS Number

Details of any other person accompanying applicant Relationship to Applicant _________________________ Date of Marriage _____________

Name _____________________________M F DOB: _________

NHS Number

Address

M

(First, M.I. Surname):

2

Address of Applicant ______________________________________________________________________________

____________________________________________________________Postcode_____________ Email Address

Type of accommodation House Flat Bungalow Care Home Other __________

Home Phone Number _________________ Mobile Phone Number ______________________

Next of Kin/ Other family/ significant other Relationship to Applicant ______________ Name ________________________________________________________________________ Address _______________________________________________________________________ Telephone Number ______________________________________________________________ Friends and Family who support me Name ________________________________________________________________________ Address _______________________________________________________________________ Telephone Number ______________________________________________________________ Name ________________________________________________________________________ Address _______________________________________________________________________ Telephone Number ______________________________________________________________

Health Care Professional e.g. Doctor, District Nurse, Social Worker Name ________________________________________________________________________ Address _______________________________________________________________________ Telephone Number

If you have the following please bring them with you

Copy of your Lasting Power of Attorney for health and welfare

Copy of your Lasting Power of Attorney for financial affairs

A do-not-resuscitate order, (DNR order) written by a doctor. (please note original only will be accepted by health care professionals)

Advanced Care Plan

3

Your stay

Period of stay requested is from _____________________to_____________________

I would prefer to arrive on Monday Tuesday Wednesday Thursday Friday

I would like to stay for One week Two weeks Three weeks Four weeks

I would like the tariff Full board Half board Bed and breakfast

I need ____________ days notice or I can accept a cancellation at short notice

State briefly reason for break

…………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………..

How did you hear about Princess Marina House?

I will be using my own car : registration number:

I will be getting a lift

I will be coming by train arriving at ___________________ station I will be coming by coach arriving at ___________________

Do you need financial Assistance to pay for this ? Please see Page 4 if you do

If you would like to be assessed for Financial Assistance from the RAFBF to cover the cost of you stay and or transport to Princess Marina House to arrange a case worker appointment please contact RAFA Helpline 0800 018 2361 www.rafa.org.uk SSAFA Helpline 0800 731 4880 www.ssafa.org.uk A case worker will visit you at home to complete Section I of the application form. Please have all documents available. If you don’t require financial assistance please just complete and sign Section II and return this booklet to Princess Marina House Enquiries about applications can also be directed to info@rafbf.org.uk or by calling 0800 169 2942

4

Section I

Financial Assessment APPLICANTS WEEKLY HOUSEHOLD INCOME & EXPENDITURE (verified from relevant documents) Is the applicant, to the best of your knowledge, in receipt of all applicable state benefits, rebates and allowances?

Yes No What action is being taken?

………………………………………………………………………………………………………………………....................................

Owner occupier or tenant ?...................................................................................

EXPENDITURE Verified Weekly Arrears INCOME Verified Weekly

Rent (less Housing benefit) Earnings of Applicant (inc. overtime but less Tax and NI)

Mortgage Earnings of spouse/partner

Council Tax Job Seekers/Income Support

Housekeeping Statutory Sick/Maternity Pay

Gardener Maintenance received

Electricity State Retirement Pension

Gas Service Pension

Water Rates Occupational Pension

Other Fuels War Disablement Pension ( %)

Insurance (not NI) Pensions – Spouse

Television Disablement Pension ( %)

Satellite Incapacity Benefit Employment Support Allowance

Telephone Widows Pension (War/NI)

Broadband Child Benefit/Special Allowance

Taxi/Bus fares Working Tax Credit

Car Universal Credits

Scooter/EPV costs Industrial Injuries Disablement Benefit

Personal/Debts/loans/HP Severe Disablement Allowance

Hairdresser Disability Living Allowance – Care Component

Pets (state if guide/assistance

dog) Disability Living Allowance –

Mobility Component

House Repairs Attendance Allowance

Window Cleaner Disability Working Allowance

Cleaner Pension Credit

Carer Carers Allowances

Prescriptions Other income (give details)

Alternative therapy

Other (please specify)

Total

Total

Savings/Capital/Investments Please show amount of savings e.g. Bank, Building Society, etc.

Any other long term investments? State what they are ________________________________

£

£

5

Welfare officer/helper’s report and recommendation

This statement should give a description of the circumstances of the applicant, what the need is and the opinion of the Case Worker. Please use an additional sheet, if necessary.

Case Workers Signature _____________________________Mr/Mrs/Miss/Mrs/Other___________ Name (PLEASE PRINT) _______________________________________ Address ____________________________________________________________ ____________________________________________________ Postcode Email Address _______________________________________________________ Branch ______________________________Telephone ______________________ Date _________________________

Declaration

I declare that the information that I have given on this form is correct

to the best of my knowledge.

I agree that the information supplied on this form may be shared with

voluntary or charitable organisations and relevant statutory agencies

for the purpose of furthering my application for assistance.

The person whose details are being requested is deceased, or unable

to sign, evidence of which is enclosed (See notes below).

The person whose details are being requested in order to process the

application is unable to sign for the following reason (See notes below).

Signature of Client: Date:

Lasting Power of Attorney for health and welfare attached

Lasting Power of Attorney for financial affairs attached

In line with Information Law personal information regarding a client cannot be

disclosed without their consent. However, there are cases where the Serving/ex-Service

person is unable to sign. In such cases, further information should be supplied to the

relevant service verification office in order to confirm service. The following cases illustrate

what information should be provided:

Where the ex-Service person has died, the verification form should be accompanied

either by a death certificate, or proof of death i.e. invoice from undertaker or

confirmation of bereavement allowance or widows pension.

In cases where the Serving/ex-Service person is infirm or physically unable to sign, a

copy of power of attorney and the attorney’s consent should be provided.

Where there is no power of attorney a note from a medical professional explaining

the client’s incapacity will suffice.

In cases of estrangement, where the Serving/ex-Service person has not signed, and

as much information as possible is provided-the Service Verification offices will be

able to confirm or deny service, but in line with Information Law, no further

details can be released. 6

Signature ______________________________________________________________________

Print name _______________________ Relationship______________________Date________

7

Section II

Applicant’s Health Self Assessment Print Name (first and surname ) ________________________________ Have you ever been diagnosed with any specific medical conditions or ongoing difficulties with :

Alzheimer’s Disease (Carers please fill in section “About Me”)

Arthritis/ Joint Replacements/ Fractures

Asthma

Bowel Disease

Dementia (Carers please fill in section “About Me”)

Depression

Diabetes

Epilepsy

Heart Disease

High Blood pressure

Kidney Problems

Neurological Disorders

Obsessive Compulsive Disorder

Parkinson’s Disease

PTSD

Recent Surgery

Respiratory Disease

Skin Conditions

Stroke/TIA’s

Urinary Tract Infections

Other (please name) ______________________________

Wound Care

I have no

dressings

Please advise if you have any wounds or ulcers that will require attention during your stay.

Yes I have dressings: Where? ………………………………………………..

They require changing : When? ……………………………………………..

OFFICE USE ONLY GCASE Number

8

Personal care

Do you have professional carers visiting you at home? (Tick one box) If yes, how many times each day? Please state number of times.

I do not currently have any support at home.

I have part time family member or friend who helps me at home. ------ times a day

I have a family member or a part time carer who helps with my personal care and other issues around the home. -------times a day

I have a live in family member or full time carer or I currently live in a care home and am supported 24 hours a day. -------- times a day

Washing and Bathing (Tick one box)

I can bathe independently. Go to the next question

I can shower independently but require assistance for a bath.

I require the assistance of one carer to maintain my personal hygiene.

I require the assistance of 2 carers to maintain my personal hygiene.

Dressing (Tick one box)

I can dress independently. Go to the next question

I need support with zips, buttons and hosiery.

I require the assistance of one carer to help me dress

I require the assistance of 2 carers to help me dress.

The support I need with things like dressing, washing and teeth cleaning is …....………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………

9

Toileting (Tick one box)

I am independent Go to the next question

I am independent with a toilet frame or raised seat. Go to the next question

I require the assistance of a carer.

I require the assistance of two carers and a commode at night.

Continence (Tick one box)

I am continent Go to the next question

I use pads to maintain my independence. Go to the next question

I am incontinent of urine and require assistance from a carer and continence aids.

I am doubly incontinent and require full assistance from two carers.

How I use the toilet when I am well e.g. continence aids and getting to the toilet …....………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

Additional Information

Protection to bed

Pads used

Catheter

Stoma Bag

Weight

Under 12 stone

12 to 15 stone

15 – 20 stone

Over 20 stone

10

Eating & Drinking

Do you have any special dietary requirements? Yes No

If yes please tick relevant box

Diabetic

Yes

Gluten Free

Yes

Low Fat

Yes

Other (Describe)

Please attach your diet sheet Now please tick yes to one of the following

I can eat and drink independently.

Yes

Providing food is cut up I can eat and drink independently.

Yes

Providing food is liquidized I can eat and drink independently.

Yes

I require some assistance with eating and drinking.

Yes

I require supervision at all times while I am eating and drinking.

Yes

Do you have any food allergies? If yes please write them here

Choking

If there is a risk you may choke please give details of your management plan and seating & posture

11

Medication

I do not take any medication

I do take medication and I am able to self medicate

I will need reminding to take my medication but I am able to give it to myself

My medication needs to be given to me by my carers

One tablet at a time On a spoon

Via a syringe I need help to make sure I have swallowed

Have you been prescribed any of the following drugs in the last two years?

Sedatives/Tranquilisers e.g. Trazidone , Diazepam , Lorazepam , Estazolam Yes No

Anti-psychotic drugs e.g. Chlorpromazine Amisulpride , Haloperidol, Pimozide,

Trifluoperazine Sulpiride Clozapine Olanzapine Quetiapine, Risperidone

Remember to bring with you

An up to date repeat prescription

All your medication in a pharmacists blister pack or original packaging

Please attach a copy of your most recent prescription.

Allergies to medications

Name the medication

Reaction You Had

Anti-Coagulant please name below

Yes No

Yes No

12

Mobility

Please bring your own walking frame/rollator. We are unable to provide these for you

I have no mobility issues. I am mobile both indoors and outdoors without assistance.

Go to the next question

I am mobile with the use of an aid indoors and am able to sit and stand independently. Please indicate type of aid in box below headed additional information

I am mobile with an aid but require assistance in getting up and sitting down and transferring. Please indicate type of aid in box below headed additional information.

I have no mobility without carer and assistance. Please indicate type of aid in box below headed additional information.

Are you able to use stairs? Yes No

Are you a wheelchair user? Yes No

Is your wheelchair electric? Yes No

Do you require an electric mobility scooter if available? Yes No

Do you require wheelchair if available? Yes No

Additional Information e.g. What equipment do you use in your home?

Walking

stick

Crutches Zimmer

Frame

Wheeled Frame

Profiling

or Hospital Bed

Standing Hoist Full Body

Hoist

Turntable

History of falls (Tick one box)

No history of falls Go to the next question

I have occasional falls but I am usually able to get up unaided

I fall frequently but I am usually able to get up unaided

If I fall I need to be hoisted

13

Keeping me safe - Do I explore? Could I fall out of bed? Please consider environmental risks

Sleep Patterns (Tick one box)

I have no problems with my sleep pattern.

Go to the next question

I have occasional problems with sleeping.

I take medication to sleep well at night. I may require some reassurance.

I have trouble sleeping at night and may require support from a carer.

How I usually am – for example do I sleep a lot, am I usually very quiet?

Communication

Sight (Tick one box)

No sight

issues.

I wear glasses/contact

lenses and

require carer support

with these and help

cleaning them

I am registered

blind / partially

sighted and

require assistance

from the carers.

I am blind /

partially

sighted and use a

guide dog and will

require support

from the carers.

Hearing

(Tick one box) I have no

hearing

issues.

I have hearing aids

/issues but manage

with minimal help. I

know how to put it in

and turn it on

I have hearing aids

/ issues and need

assistance putting

it in and turning it

on

I am registered as

being deaf and

require

a large amount of

support.

14

Speech (Tick one box)

I have no

speech

issues. I can

communicate

without help.

I have speech

difficulties but

can communicate

without difficulty.

My speech is

distorted and may

require extra

support to be

understood.

I am unable to

verbally

communicate

I communicate

using aids.

Other ways I communicate if applicable – Signing, pictures or other languages? How I show how I feel. How I communicate yes and no.

Understanding (Tick one box) I have no

problems

understanding

people or

remembering

information

I have occasional

difficulty remembering

information

I have memory

loss which affects

my day-to-day

living and / or I

have been

diagnosed with

dementia in

the last two years.

I have memory loss

which affects my

ability to care for

myself and/or have

been diagnosed

with dementia

more than two

years ago.

How I show I’m in pain and how to support me

I agree that information collected as part of the application process may be retained so that any future applications may be speedily processed, and that data generated may be used for follow up assistance, statistical and research purposes. I confirm that the information I have provided in the above assessment is a true indication of my care needs. I give permission for The Royal Air Force Benevolent Fund to contact my GP or any other Health Care Professional if there are any concerns relating to the information I have given.

Signature …………………………………………………………………

Print Name ……………………………………………………..

Date………………………………………………

15

About Me ONLY FILL THIS SECTION IF YOU TICKED “been diagnosed with Alzheimer’s Disease or Dementia” on page 7 Are you prone to infection? Yes No

If yes, Urine Chest Other___________________________________________

In the event of an infection have you ever

Become verbally aggressive? Yes No

Become paranoid (suspicious of people around you)? Yes No

Become delusional? Yes No

Thrown or broken anything? Yes No

Hit out at person/persons? Yes No

How do you react to strange places?

Do you become anxious at any particular time of day? Yes No

If yes, when? ___________________________ How is this displayed? tick any box

Wandering Inability to sit still Constant questioning

Accusations of persecution Verbal aggression Throwing things Hitting out

16

Things that may worry or upset me (foods, activities ) – How I may show this

How to support me if I am anxious or upset

Behaviors I have that may be challenging or cause risk. What you can do to support me with my behaviors – things that help me relax

Things I like include: Music, TV, foods, activities and how I relax

17

My History- What is important that you know about my life (past and present) including previous employment

If this section is completed by a family member or carer please sign in the box below

Signature ………………………………………………………………… Date………………………………………………………………………… Relationship to applicant ……………………………………………

Declaration Data Protection Act The information provided by the applicant is given in confidence and is in line with Information Law.The Royal Air Force Benevolent Fund may share this information with third parties in order to seek/secure further funding. Thank you for taking the time to complete this form.

For more information about the RAF Benevolent Fund and its work visit www.rafbf.org

Royal Air Force Benevolent Fund, 67 Portland Place, London, W1B 1AR020 7580 8343

The RAFBF is a registered charity in England and Wales (1081009) and Scotland (SCO38109)

CobseoThe Confederation

of Service Charities

RAFBF Caseworker report 23 Sept.indd 8 23/09/2015 22:23