Book a Service (Online Assessment)

Before you begin using any of our services we’d love to learn a little more about you. This is so that we can provide you with a bespoke befriending service that caters to your specific needs.

Please complete the assessment form below. If you’d prefer a face-to-face assessment instead then please contact us.

Any personal information you provide to us at any time is protected under the Data Protection Act 1998 and therefore is treated with the utmost privacy, transferred through a secure server with 2048-bit encryption, stored securely and is only accessible to key HaywardBefriending staff. We will never share your information with any unauthorized third parties.

* indicates a required field

Personal Details

Your name/Name of client*

If completing this form on behalf of someone else, please put YOUR name here, and THEIR name in the above box:

Your email*

Your telephone number*

Your full address*

Name of next-of-kin*

Address of next-of-kin*

Preferred language*

Name of GP*

Address of GP's surgery or practice*

Do you have a religion? (if none then leave blank)

Medical Conditions

Do you have a physical disability?*
 Yes No

If "yes", please explain your physical disability:

Do you use a wheelchair?*
 I don’t use a wheelchair Yes, when I need a rest from walking Yes, when out and about Yes, most/all of the time

Do you use any mobility aids?*
 I don’t use any mobility aids Walking stick Walking frame Cane Crutches

Do you have a learning disability?*
 I don’t have any learning difficulties Mild Moderate Complex

Do you have any sensory disabilities?*
 I don’t have any sensory disabilities Visual Hearing Visual & Hearing

How does your disability/disabilities affect your every day life?
Please include as much information as possible. If this does not apply to you, then please leave blank.

Do you have any allergies?
If none then leave blank

Medical History

Have you ever had any of the following conditions?
Please select ALL options that apply to you

 Chest Pain Asthma Bronchitis Pneumonia Heart Problem Varicose Veins Difficulty Breathing Rheumatic Fever Stomach Problems Stomach Ulcer Ear Problems Swollen Legs Fainting/Blackouts Seizures Dizziness Diabetes Repetitive Strain Injury Nervous Problem High Blood Pressure Migraine Skin Problem Rheumatism Joint Problems Hayfever Bowel Problems Kidney Problems Chronic Back Pain Rupture

If you have experienced any of the above conditions, please give details:

Getting to Know You

Please select which option you feel best applies to you:

I feel that I am...*
 Happy most of the time Happy sometimes Never Happy Angry all of the time Angry sometimes Never Angry

I like...*
 Being with other people Sometimes being with other people To be on my own

I prefer...*
 Group activities Activities by myself Both

I would use the following words to describe myself...*
Please select ALL options you feel apply to you
 loud confident quiet shy talkative good at listening creative

Do you have any hobbies, regular activities or special interests? (if none then leave blank)

Day-to-Day Living

Personal Care*
 I do this myself I have a personal assistant Family member supports me An agency supports me
If using an agency, please put the name of the company here:

PLEASE NOTE: HaywardBefriending is unable to offer personal care support. If you need assistance with personal care please contact us so that we can connect you to our personal care company HaywardCare.

Daily activities and getting out and about:*
 I do this myself I have a personal assistant A family member supports me I need support

Managing my own finances:*
 I do this myself I have a personal assistant A family member supports me I need support

Professional Support

Do you have a social worker?*
 Yes No
If you selected "yes" please provide the following details:
Name of social worker:
Contact number of social worker:

Do you have a community nurse?*
 Yes No
If you selected "yes" please provide the following details:
Name of community nurse:
Contact number of community nurse:

Do you have any other professional support?
If "yes", please provide a name and contact telephone number for each professional support. If "no" then please leave blank.

HaywardBefriending Services

Click here for details on all our services.

Please select our services that you might be interested in:
This information is for your initial assessment only and is NOT a booking confirmation. You can make changes to your choice of service(s) at any time.

 Accompanied Holidays Company at Home All-Night Service Meal Preparations Support with Paperwork & Correspondence Handy-person Service Shopping with You Shopping for You Support with Housework Gardening Appointment Transportation Hospital Visits Accompanied Outings Exercise Social Activities Pet Service Computer Skills

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