Adults' Health and Care new or additional support request

Before completing this form, we recommend that you visit Connect to Support Hampshire to explore what help and support is available in your area. Many of the community based services listed in the Community Directory are free or low cost and available to everyone.

The services that we offer may require a financial contribution and the amount that may need to be contributed will be subject to a financial assessment. If the individual has more than £23,250 savings then they are likely to have to pay the full cost.

Your details
Manually enter your address if you live outside Hampshire, or you cannot find your address
For example: 31 12 1980
The AS reference can be found any correspondence from Adults' Health and Care
Manually enter the address if the address is outside Hampshire, or you cannot find the address
Initial Questions
Is this about you or someone else? required
Has the individual consented to you making this request? required
Does the individual have the mental capacity to make this decision? required
Can you confirm this is in the individual's best interest? required
Individual's details
Manually enter the address if the address is outside Hampshire, or you cannot find the address
For example: 31 12 1980
The AS reference can be found on correspondence from Adults' Health and Care
The NHS number will be on any letter or document received from the NHS, such as prescriptions, test results and appointment letters
Manually enter the address if the address is outside Hampshire, or you cannot find the address
Next of kin/carer details
Do you have any next of kin/carer information? required
Manually enter the address if the address is outside Hampshire, or you cannot find the address
For example: 31 12 1980
Questions about support request
For example: washing myself, getting dressed, using my home safely
For example: 'I have recently been ill' or 'My health has declined'
For example: 'I can strip wash' or 'I have tried using a neighbour's shower'
For example: family, paid support, health professionals, housing professionals, voluntary sector, carer/ care provider
For example: equipment, spoken, technology, interpreter
optional
 
 

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