Breach House Care Home

Applicant's name

Applicant's date of birth

Applicant's home address

Applicant's religous beliefs

Applicant's national insurance number

Applicant's current residency

Resident's address

Resident's telephone

Contact's name

relationship to applicant

Home phone

Mobile

Work phone

Email Address

How did you hear about us?

Private funding?
NoYes

Cheshire county council funded?
NoYes

If 'yes' to above, has the funding been approved?
NoYes

Social worker's name

Social worker's telephone

Does the applicant need help with washing?
NoYes

Does the applicant need help with dressing?
NoYes

Does the applicant need help with washing?
NoYes

Does the applicant need help with toileting during the day?
NoYes

Does the applicant need help with toileting during the night?
NoYes

Does the applicant have incontinence problems during the day?
NoYes

Does the applicant have incontinence problems during the night?
NoYes

Does the applicant wander during the day?
NoYes

Does the applicant wander during the night?
NoYes

Is the applicant prone to falling?
NoYes

Does the applicant need help with feeding?
NoYes

Does the applicant need the use of walking aids?
NoYes

Has the applicant ever had a stroke?
NoYes

Does the applicant wear glasses?
NoYes

Describe the applicant's sight

Does the applicant have hearing problems?
NoYes

Does the applicant wear a hearing aid?
NoYes

Does the applicant have their own teeth?
NoYes

Does the applicant have dentures?

Are you appointee or do you have power of attorney for the above applicant?
NoYes

Please list any hobbies, likes and dislikes the applicant may have

Application Form for Residency at Breach House Home Ltd