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
The following information is about the person needing care.
Details of health including: Ability to communicate and understand, Level of mobility, Any challenging behaviour, Continence
Details of medication Required
Treating doctor`s name, address and telephone numberRequired
Describe the care the patient is presently getting and say who is cares for him/her Required
Husband/wife/partner Required
ChildrenSet in order of age give their gender and date of birth
Do you have a will? If you do please provide a copy of your latest will. Who holds the original will?
Do you have either an enduring or lasting power of attorney? If so, please provide a copy of the document.
Has any application been made to the Court of Protection? If so, please provide copies of any applications or orders.
Full address of your home? 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.
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.
Give details of any life insurance policies-please bring your policies with you to the meeting.
Interests in a business
List details of state and occupational pensions, state Benefit and any other income. Please state the amount received and if weekly, monthly or annually
Liabilities including long term secured loans
Click here to visit our free advice clinic page. No appointment is necessary!