Download our Questionnaire here
The following information is about the person acting for the patient.
Name Required
Address Required
Date of Birth Required
Occupation Required
National Insurance number Required
Tel no (home/work/mobile) Required
Email Required
Status Required Single Married Divorced Widow Partner
To be completed by or on behalf of the patient (person needing care):
Details of health including diagnosis and prognosis
Details of medicationthat may affect decision making abilityRequired
Treating doctors name, address and telephone numberRequired
Details of social worker including name, address and telephone number
What arrangements have been made for domestic assistance and care?
Husband/wife/partner:
Children. Please give details in order of their age. Please list their gender and and date of birth
Please submit a Family Tree to us via email or post
Other DependantsPlease state any other dependants
Do you have a will? If you do please provide a copy of your latest will. Who holds the original will?
Power of Attorney Have you made an Enduring Power of Attorney (EPA), Lasting Power of Attorney (LPA) for property and affairs or Lasting Power of Attorney (LPA for personal welfare? If so, have these been registered with the Public Guardian? Please provide details of any orders.
Has any other application been made to the Court of- Protection?If so, please provide a copy of the document.
Are you in a private nursing home or residential care? Are you in a local authority nursing home or residential care? Please give details including the address and telephone number
Full address of your home? What is the present value?
Is it freehold or leasehold?
How is your home held? Solely or jointly? If joint, is it as joint tenants or tenants in common?-where possible please provide a copy of your deeds. If you do not hold the deeds please let us know who does.
If you do not own your home please state if it is privately rented or local authority. Please give details of your landlords
List other assets held and their approximate value, including bank and building society accounts, shares, and pension funds. Say if they are held solely or jointly and if jointly with whom.
Other land and properties
Bank Accounts
Building Society details
Shares
Pension Funds
Business
Life insurance policies-please bring your policies with you to the meeting
List details of state and occupational pensions, state benefit and any other income. Please state the amount received and if weekly, monthly or annually
Please give details of any other income you may receive
Are you entitled to any income, property or capital from a trust? If yes, please give details
Do you have any interest in the estate of someone who has died?
Please give an overall estimate of the value of your personal possessions. If any of your possessions are particularly valuable please list them and provide an approximate valuation.
If you are in a nursing home please state the cost of The accommodation and whether its paid monthly or Weekly.
Please state whether or not you have been assessed by the Local Authority to pay contribution towards your care costs
Please give details of all liabilities including long term secured loans
The Court of Protection require at least three close family members or friends to be notified of the application. Please give names, addresses and telephone numbers of people to be notified.
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