EmailMe Form - Application for Residency at Derbyshire House

Application for Residency at Derbyshire House

Please make every effort to fill all of this form in so that we can add you to the pending applications list
Please note that you do not have to complete this form in one session but it must be submitted within 21 days of initial editing. To save and resume scroll to the end of the form and click on 'Save & resume later'
BE AWARE THAT IF YOU SIGN OUT BEFORE COMPLETING THE FORM THAT YOU WILL RECEIVE A LINK. PLEASE MAKE A CAREFUL NOTE OF THIS AS IT IS THE ONLY WAY TO GO BACK TO COMPLETE YOUR FORM.

Please read the notes below before completing this application.
Please note that if you are self-funding, you must be able to fund your stay at Derbyshire House for a minimum of 5 years. If you are unable to do this and need to apply for funding from the local authority then a third party top-up is required to the relevant fee. It is in your best interests to contact your Local Authority Social Services Department for an assessment of your care needs whether you are self-funding or seeking Local Authority funding. If you are only able to self-fund your stay for a limited period of time, the Local Authority will not automatically fund your residency unless a Social Worker has assessed that you are in need of Residential care. The funding you receive from the Local Authority may not be sufficient to cover your agreed fees and may require a third party top-up by your family /representative.
Applicant details
Applicant's name *
First Middle Last
Maiden name
Likes to be called
Former occupation
Marital status
Religion
Personal pronoun
What would the applicant like to be referred to as (personal pronoun) for example he, she, they, them etc. *
Present address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone
Email
Birth place
Date of birth *
National Insurance No. *
NHS No. *
Please note:
We will need you to provide documentation of all medications and the reasons for taking this medication and any underlying health problems that you may have.
Name of doctor
Medical practice *
Practice address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Contact details for next of kin
Name (Next of kin) *
Address (next of kin) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone (Next of kin)
Email (Next of kin)
Does this p[erson hold Power of Attorney?
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Does this person have a lasting personal welfare power of attorney? (The home will need to be provided with copies of these if available)
Name address and telephone number of two other family members or friends that could be contacted in an emergency.
Name (Family member 1)
Phone (Family member 1)
Address (Family member 1)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Name (Family member 2)
Phone (Family member 2)
Address (Family member 2)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Solicitor details
Solicitor Name
Solicitor (Practice name)
Address (Solicitor)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
References
Name (Reference 1)
Phone (Reference 1)
Address (Reference 1)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone (Reference 2)
Name (Reference 2)
Address (Reference 2)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Emergency contact
Name (contact) *
Address (contact) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone (contact) *
Email (contact)
Application notes
Dropdown List

Is this application urgent?

Will you be funding yourself?

Will you require local authority funding?
1 / 4

Is this application urgent?
Will you be funding yourself?
Will you require local authority funding?

Please read the notes below before completing this application.

Applicant details

Please note:

Contact details for next of kin

Name address and telephone number of two other family members or friends that could be contacted in an emergency.

Solicitor details

References

Emergency contact

Application notes