Kentown assessment form This form is for internal use, by Kentown team members, during the assessment process. Please complete following a referral Assessment detailsPerson completing the assessmentBenLoriStephDate of assessment Month Day Year Ken number WelcomeHello, my name is _____. I’m calling from the Kentown project. I’m one of the Family Service Coordinators. Just checking: is now still an okay time to talk? I’m ringing to see how we could best support you. It shouldn’t take us any longer than fifteen minutes. Is that okay? Yes No No problem, when would be a good time to reschedule? Month Day Year Input preferred date hereWelcome packDid you receive our welcome pack (if not, please explain the project to the recipient)? Yes No Sorry to hear that. Would you like me to send one out? Yes No How did you find the information in the welcome pack? Is there anything you don’t understand, or anything you'd like me to run you through again? Yes No Can I just check—do you know much about my role within the project (please explain role as required)? Yes No Consents: Before we take this any further, I'll just check we have the right details in our records.(FSC please amend referral spreadsheet as necessary)Please confirm your name… First Last … the first line of your address… Address line 1 … email… … postcode… Postcode … and phone number.Great, thanks for that. So that we can support you further, I just need to get a bit of an understanding of your situation. Could you tell me what’s been going on for you?Thanks for sharing that with me. It sounds like you could benefit from the project. Have you spoken to either the nurse or anyone from Rainbow Trust yet (please add who has made contact with the family)? I’m going to run through a few questions with you now. Some might need some personal information, such as your financial situation, so that we can assess whether there are any grants you might be eligible for, is that okay? Yes No What are your worries around sharing this and is there anything I can do to make this easier for you? Financial situationAre you in receipt of any benefits for yourself or child? Disability Living Allowance (DLA) Carer's Allowance (CA) Universal Credit (UC) Child Benefit (CB) Housing Benefit (HB) Other If other, please list. Do you have a rough idea of your household income? How do you pay for your gas and electricity bills? Are you on the Priority Service Register (if unsure, please explain the PSR)? Yes No I don't know Do you have any energy debt? Do you have any other financial struggles that you'd like us to be aware of? Yes No If so, please provide details.HousingWhat's your current accommodation type?Homeowner outrightHomeowner with a mortgageHomelessLiving with friends/familyLiving with parentsPrivate rentedRoom in a houseshareShared ownershipSocial tenantTemporary housingRefugeOtherIf other, please state. Who else lives at home (including anyone under 18)? Do you have any concerns about your property or appliances within the home? Yes No If so, what are your concerns?MobilityDo you have access to a vehicle? Yes No If applicable, do you have a blue badge? Yes No Are there any items you need to support your child’s mobility? Yes No If so, what are the items? Are you currently regularly making planned or unplanned travel to support your child's care? Yes No If so, please provide details.Emotional wellbeingAre you or your family supported by any wellbeing services? Yes No If so, please give details. Would you like to know more about any services that work to improve emotional wellbeing? Yes No FSC ONLY: Do you have any safeguarding concerns at the time of this call? Yes No On ending this call, please report this safeguarding concern.Carer informationAre you registered as a carer? Yes No Would you like us to send you information on your local carers' centre, where you can register? Yes No If applicable, are any sibling children registered as young carers? Yes No Would you like us to send you information on your local YC service? Yes No Respite and short breaksWhat would be your ideal family day out?Is there anything you're currently unable to do but would like to do more of? Any other helpIs there anything else we can support with? Yes No If so, what? CAPTCHA Δ
