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The UK's Healthcare Law Service 
Robert Campbell & Company

0870 2412139  
rob@carelaw.co.uk  


FREE NURSING CARE ASSESSMENT

Please complete the following form as completely as possible, and click the 'Submit' button to send the form to us. Doing so places you under absolutely NO OBLIGATION following the assessment.

Information you share with us will be kept confidential and not disclosed to anyone else without your permission. We are registered under the Data Protection Act 1998 and our conduct is regulated by the Solicitors Regulation Authority.


SECTION 1 - Your Details
Your Name:
Your date of birth:  for security purposes.
Your Address::
Telephone / Mobile:
Email address:
I am The:  Son   Daughter   Wife   Other (Select one)  of  
  An NHS patient about to be discharged into a 
private nursing home at own cost;  OR:
An NHS patient who  was discharged
      into a private nursing home at own cost;
In either case:  Actual or anticipated discharge date:

SECTION 2 - Patient Details

Name of Patient: 
Patient date of birth:    If Deceased, date of death  
Power of Attorney:   Do not hold Power of Attorney     
Hold Power of Attorney/Deputyship or Receivership
Address  of Patient: 

SECTION 3 - Symptoms / Diagnosis
General description of patient's condition

A.


Please describe briefly the patient’s condition, problems encountered in the past few years and any diagnosis.

 


 
B.

 
Please select each of these items that (in your view) best describes the patient’s condition/needs:

          

Need/Symptom Low/None Moderate  Severe





Physical Diseases

Mental state 

Mobility 

Feeding 

Continence


C.
MENTAL HEALTH ACT
Has the patient ever been subject to detention under The Mental Health Act 1983?. If so, please give details:


No   Yes (Pleas give details below)
Details:


SECTION 4 - Steps taken to obtain continuing care funding
Here describe briefly what has been done and the current outcome: 


SECTION 5 - Trust responsible for care
Name and address of Trust responsible for the patients care 
(if known):


SECTION 6  - Any other relevant information
Approximate financial losses (Care fees) £?:
Please tell us anything else of relevance. For example has the patient’s condition recently worsened? Is there an outstanding complaint to the Ombudsman?:


SECTION 7  - Market Research etc.
Please tell us where you heard about this web site:

We try to keep our clients informed as to developments in areas of interest to them. Unless you check this box we will assume you wish to be included when we send out these up-dates. 

 

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 Robert Campbell & Co., Greenhills, Winsham, Braunton EX33 2LX
 Regulated by the Solicitors Regulation Authority. SRA No. 00327671
© web content copyright © Robert Campbell 2010
web design and code  © 56kb.com 2010

 

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    

 

Back to the top


 Robert Campbell & Co., Greenhills, Winsham, Braunton EX33 2LX
 Regulated by the Solicitors Regulation Authority. SRA No. 00327671
© web content copyright © Robert Campbell 2010
web design and code  © 56kb.com 2010

S