A&A form

Consent for storing submitted data *

Yes, I give permission to store and process my data

Tenant's permission *

Tenant's permission

Medical Professional information

Full name *

Job title *

Contact number *

Team/Location *

Email address *

Date of assessment *

Applicant details

Title *

First name *

Surname *

Date of birth *

Age *

Address *

Postcode *

County *

Contact name/number *

Email address *

Property information

Flat: Is the building lift-serviced?

Yes

Number of lounge/dining rooms on the ground floor *

Type of bathroom *

Over bath shower

Bath only

Level access shower

Shower cubicle

What floor is the bathroom on? *

Is the toilet separate to the bathroom? *

Yes

What floor is the toilet on? *

Adaptations already present *

Stairlift

Grab rails

Ramped access

Level access shower

Over the bath shower

Through floor lift

Level taps

Other

None

Other adaptations *

Functional abilities of applicant / medical condition

Medical condition - functional abilities and potential for deterioration *

Mobility: ambulant / wheelchair / equipment required *

Transfer abilities: equipment / assistance *

Continence issues: how is it managed (if applicable)? *

Options considered / rejected

Please provide detailed information, the application may be delayed if all alternative equipment/adaptation provision have not been considered and reasons why not appropriate detailed below. For example - all applications for level access showers will not be considered unless bathing equipment and alternative solutions have been assessed and reasons why not detailed below.

Equipment considered and reasons rejected *

Alternative adaptations considered and reasons rejected *

Has rehousing been discussed and reasons rejected *

Has DFG / alternative funding been explored and reasons rejected *

Preferred solution

Any other supporting documents or information *

Please tick this box *