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?*

If "yes", please explain your physical disability:

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

Do you use any mobility aids?*
I don’t use any mobility aidsWalking stickWalking frameCaneCrutches

Do you have a learning disability?*
I don’t have any learning difficultiesMildModerateComplex

Do you have any sensory disabilities?*
I don’t have any sensory disabilitiesVisualHearingVisual & 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 PainAsthmaBronchitisPneumoniaHeart ProblemVaricose VeinsDifficulty BreathingRheumatic FeverStomach ProblemsStomach UlcerEar ProblemsSwollen LegsFainting/BlackoutsSeizuresDizzinessDiabetesRepetitive Strain InjuryNervous ProblemHigh Blood PressureMigraineSkin ProblemRheumatismJoint ProblemsHayfeverBowel ProblemsKidney ProblemsChronic Back PainRupture

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 timeHappy sometimesNever HappyAngry all of the timeAngry sometimesNever Angry

I like...*
Being with other peopleSometimes being with other peopleTo be on my own

I prefer...*
Group activitiesActivities by myselfBoth

I would use the following words to describe myself...*
Please select ALL options you feel apply to you
loudconfidentquietshytalkativegood at listeningcreative

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

Day-to-Day Living

Personal Care*
I do this myselfI have a personal assistantFamily member supports meAn 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 myselfI have a personal assistantA family member supports meI need support

Managing my own finances:*
I do this myselfI have a personal assistantA family member supports meI need support

Professional Support

Do you have a social worker?*
If you selected "yes" please provide the following details:
Name of social worker:
Contact number of social worker:

Do you have a community nurse?*
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 HolidaysCompany at HomeAll-Night ServiceMeal PreparationsSupport with Paperwork & CorrespondenceHandy-person ServiceShopping with YouShopping for YouSupport with HouseworkGardeningAppointment TransportationHospital VisitsAccompanied OutingsExerciseSocial ActivitiesPet ServiceComputer Skills

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