Assessed by

Assessment date

Referred date

Personal Details

Preferred name

Date of birth

Accommodation

Contact number

Email

GP surgery

Emergency contact details

Emergency contact name

Emergency contact relationship

Emergency contact number

Do they have a smart phone, iPad or Tablet?

Are they a carer?

Are they cared for?

Ethic group

How many social contacts do you have in a fortnight?

Do you currently volunteer / give you time to others in your community?

Family profile

Have you been bereaved within the last 12 months?

Who do you go to in a crisis/emergency?

Past and current interests, hobbies and work life

Times to call

Do you have a pendant alarm?

Further health information

How often do you feel you lack companionship?

How often do you feel left out?

How often do you feel isolated from others?

How would you rate your general wellbeing? (scale of 1-5)

(1: LOW, 5: GOOD)

How connected do you feel to your neighbourhood/community?

(1: LOW, 5: GOOD)

More information

How easy it was to chat over the phone?

I agree that the personal information collected here can be held by The Link Visiting Scheme on computer systems and paper documents as required by the charity for its efficient operation, in accordance with the General Data Protection Regulation 2018. The information you have provided will not be disclosed to any outside organisation. More detail can be found on our policies, and the rights you have regarding your own personal information, on line at www.linkvisiting.org/privacy, or on request directly from the charity by emailing us at admin@linkvisiting.org, or calling on 0118 9798019

Telephone Assessment