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You are here: Home » Care & Support » Social Care Services » Getting help from Social Services » Help for Adults » Equipment and Adaptations » Equipment and Adaptations Self Referral Form

Equipment and Adaptations Self Referral Form

If you think that you only require small items of equipment, you can complete this self referral form. This form will be dealt with during office hours which are Monday to Thursday 8.45 am to 5.15 pm, Friday 8.45 am to 4.45 pm.

Information you supply on this form will be held by the Sheffield City Council. Any personal information you supply will only be used for the purpose(s) of your enquiry and will not be disclosed to any third parties unless otherwise stated. If you want to ask any questions about our use of your information, please contact: adultaccess@sheffield.gov.uk. We have a Data Protection Officer in the Chief Executive's Directorate.

Also please be aware that the Internet is not secure and information given on this form or by e-mail should be considered public. We are developing more secure ways for people to communicate with us over the Internet and we will make it clear if you are using one of these.

» Required Fields

» Full Name:

» Address:

» Postcode:

» Date of Birth:

Telephone Number:

GP Details:

» Name:

» Address:

Next of Kin or Emergency Contact:

» Name:

» Telephone Number:

» Relationship to you:

Accommodation Details:

» Do you live in:

House
Bungalow
Ground Floor Flat
Upper Floor Flat

Number of steps into the property:

» Front:

» Back:

» Accommodation:

» Do you receive income support?

Yes
No

» Do you live alone?

Yes
No

If not who else lives with you:

» Do you have a hearing problem?

Yes
No

» Do you need a signer?

Yes
No

» Do you have a visual impairment?

Yes
No

Are there any potential problems we should be aware of before visiting you, ie you have difficulty hearing the door bell; you have a dog that may frighten someone; we need to arrange for someone else to be present at the assessment etc:

» Is English your first language?

Yes
No

If not please specify:

» Do you require an interpreter?

Yes
No

» What is your ethnicity?

» What is your disability or condition?

» What are you having difficulty with?

» How or what do you think we can help you with?

» How are you managing at present?

» Getting a wash and personal hygiene – current bathing facility:

Bath
Shower over bath
Shower cubicle
Level access shower

» Do you use the bath or shower?

Yes
No

» How do you bathe?

» Have you ever tried any equipment (eg bath board, bath seat, bath lift etc)?

Yes
No

If yes, what was it and why wasn’t it suitable?

» Do you have a carer?

Yes
No

If yes, who are they?

What do they help you with?

» Have you ever had a visit from Equipment and Adaptations before?

Yes
No

If yes, approximately how long ago?

Thank you for taking the time to complete this form.

If we need any further details a member of staff will ring on your home number. However if you would prefer to nominate someone who will help us on your behalf please give their details below.

Name:

Telephone Number:

Relationship to you:

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