Practitioners and Clinicians' Telecare Requisition Form
Primary Information

(Please tick the selected box throughout this form)

Organisation / Department Details

 

Client & Property Details

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Hospital Discharge

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GP's Details Click here>>



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Cost of Indicative Budget per Annum: £

What is different in terms of the support plan (outcomes) by providing Telecare services as opposed to NOT providing them? Click here>>

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Please detail any other information about the client's condition or situation that you feel may be relevant e.g. number of times an issue has already occurred and/or the extent of the issue:

Capacity Click here>>

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Client Consent/Mental Capacity Click here>>

Yes No
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Key holder Information:(Please tick boxes as appropriate) Click here>>

Yes No
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Access Check List:
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Name, address, & phone numbers of persons that can respond in an emergency Click here>>

 
 

What services does the client already receive? Click here>>

Service Type Provider No. Hrs/ visits per week

Current Utility Services at the Clients’ Property Click here>>

Gas Electricity Water Telephone* Telecare
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Yes No
 



please type the first 3 letters of the local authority and select the appropriate one from the list