Assessment Form | Caring Alliance

Individual Details

Full Name

Date of Birth

Preferred Name

Address

Phone Number

Email

NHS Number (if known)

Date of Assessment

Assessor Name

Assessor Role

Setting / Service

Review Date

About Me

This section is about who the person is, what matters to them, and how they wish to be supported.

What is important to the person? (values, relationships, hobbies, faith, culture, daily routines)

What are the person's goals and aspirations?

How does the person communicate? (language, verbal, non verbal, aids, interpreters needed)

Who is important to the person? (family, friends, advocates, pets)

What does the person want staff to know about them to provide good support?

Physical and Health Needs

General Health Summary

Diagnosed Conditions

Mobility and Moving and Handling Needs

Medication (current and any allergies)

Skin Integrity Needs

Nutrition and Hydration Needs

Sleep Patterns and Needs

Sensory Needs (vision, hearing, touch)

Continence Needs

Oral and Dental Care Needs

Mental and Emotional Wellbeing

Mental Health Summary

Diagnosed Mental Health Conditions

Emotional Needs and Triggers

Behaviours that Challenge

Self Harm or Risk Indicators

Memory and Cognition

Coping Strategies that Help

Current Therapies or Interventions

Mental Capacity and Consent

Mental Capacity Assessment (specific decisions)

Best Interest Decisions Recorded

Deprivation of Liberty Safeguards (DoLS) Status

Advance Decisions or Statements

Lasting Power of Attorney (health and welfare)

Consent to Care and Treatment

Personal Care and Daily Living

Personal Care Needs (washing, dressing, toileting)

Meals and Meal Preparation

Domestic Support Needs

Financial Management Needs

Shopping and Errands

Transport and Community Access

Independence and choice: what can the person do for themselves, and what would they like support with?

Social and Community Life

Current Social Activities and Interests

Community and Faith Connections

Employment, Education, or Volunteering

Social Isolation or Loneliness Concerns

Activities the Person Would Like to Try

Relationships and Support Network

Safeguarding and Risk

Safeguarding Concerns or History

Current Risk Assessments in Place

Risk to Self or Others

Environmental Safety Concerns

Substance Use (alcohol, drugs, prescribed)

Exploitation or Financial Abuse Risk

Equality, Diversity, and Inclusion

Protected Characteristics (as defined by Equality Act 2010)

Religion, Faith, or Belief

Cultural Needs and Practices

Dietary Requirements (cultural, religious, medical)

Sexual Orientation and Gender Identity

Communication and Language Preferences

End of Life and Future Planning

Advance Care Plan in Place?

End of Life Wishes (if appropriate to discuss)

Preferred Place of Care at End of Life

Future Planning and Goals

Outcomes and Support Plan Summary

Identified needs and desired outcomes

Support and interventions to be provided

What does success look like for this person?

Agreed Actions

Action	Responsible Person	Due Date	Status

Sign-Off

Role	Name	Signature	Date
Assessor
Individual / Representative
Registered Manager

Holistic Person Centred Assessment Form