Adult Social Work Referral Form

The following self-assessment will help you understand your strengths and abilities, providing advice for how to build on your skills and suggested supports where you need help. Once complete, you will be provided with advice support and information based on your responses. If appropriate, you will be able to refer on for a fuller assessment.
Personal Care
1. Tell us about your ability to undertake the following tasks.
2. Bathing *
  
  I can do this independently
  
  Able to do alone but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this
4. Getting out of bed *
  
  I can do this independently
  
  Able to do but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this
6. Using the toilet*
  
  I can do this independently
  
  Able to do alone but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this
8. Getting dressed*
  
  I can do this independently
  
  Able to do alone but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this
10. Eating or Preparing Meals*
  
  I can do this independently
  
  Able to do alone but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this
12. Taking Medication*
  
  I can do this independently
  
  Able to do alone but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this
Accessing the Community
1. Do you require support to maintain or develop social relationships?*
  
  Yes
  
  No
3. SOCIALRELATIONSHIPADVICE
  1. You may wish to consider asking a family member or friend to support you to access the community or develop social relationships. There may also be community groups and organisations that could help you meet this need. Our community hubs could offer appropriate advice and guidance.
    
    Community Connections
4. Do you feel physically able to go out of the house independently and undertake tasks / activities?*
  
  Yes, I can do this independently
  
  Able to do alone but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this
6. Do you feel mentally able to go out of the house independently and undertake tasks / activities?*
  
  Yes, I can do this independently
  
  Able to do alone but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this
Managing Tenancy / Household
1. Tell us about your ability to undertake the following tasks.
2. Light Housework *
  Tasks that are generally less physically demanding, such as, dusting, washing dishes, and tidying up.
  
  I can do this independently
  
  Able to do alone but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this
4. Heavier Housework *
  More physically intensive tasks like deep cleaning, moving furniture, and scrubbing floors.
  
  I can do this independently
  
  Able to do alone but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this
6. Household Shopping / Managing Finances*
  
  I can do this independently
  
  Able to do alone but often find difficult
  
  Able to do alone with the help of some equipment / technology
  
  Able to do but need help from someone else
  
  Unable to do this

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Adult Social Work Referral Form