Care fees questionnaire

Care Fees Questionnaire

To receive your FREE, no obligation initial care fees report - please complete the questions as fully as possible, but don’t worry if you can’t answer some of them, we will still be able to send your report.

You can complete this online or print off and send to us in the post.

YOUR OBJECTIVES

What would you like to provide for?

The cost of care in your own home?

The cost of care in a care home with nursing facilities

The cost of care in a care home (residential only)

Now

Very soon

In the future

Please state the amount you have been quoted (either weekly, monthly) or per annum) for care fees. If you have not yet received a quotation, please state the area of the UK where the care is intended to take place and we will estimate an average figure.

Cost of care

Name of care home

(if known)

Location

E.g. Town/City

Details of individual for whom care is to be provided- if more than one please complete two forms..

Title

First name

Last name

Date of Birth DD/MM/YY

Marital Status

If you are completing this on behalf of an elderly person, please state your relationship. E.g. Daughter, son, nephew, friend, etc.

Relationship

Do you hold an Enduring Power of Attorney

If so is it registered with the Guardianship Office?

Do you hold a Lasting Power of Attorney?

(Lasting Powers of Attorney have been introduced on the 1st October 2007 and replace the existing Enduring Powers of Attorney. However if you have an existing EPA this can still be used.) An LPA is automatically registered with the Guardianship Office (Court of Protection) at outset.

Financial details of care recipient

Income

Net amount

Frequency

State pension

Private pension

Attendance allowance

** Nursing contribution

**The nursing contribution is only available to residents of nursing homes and is just one rate as from the 1st October 2007. It is paid directly to the care provider and it is at their discretion as to whether it is taken of the cost of care.

Other income

Other income source(s)

Assets

Main residence

Is it your intention to sell?

Other property

Bank/Building Society account(s)

National Savings

Shares/equities

PEPS/ISAs

Unit Trusts

Investment Bonds

Brief Medical Details

Is the Care Recipient bed ridden?

Is the Care Recipient wheelchair bound?

Does the Care Recipient use a zimmer frame?

Has the care recipient fallen down in the last 6 months?

Does the care recipient suffer from poor circulation?

Is the Care Recipient suffering from any illnesses? Please include past conditions going back at least 10 years. We may need to contact you for more details.

Activities of Daily Living

Please give details of the Care Recipient’s ability to perform the following acts of daily living.

Guide-

Major assistance: always requires both assistive device and personal assistance.

Moderate assistance: requires both assistive device and some personal assistance.

Minor assistance: requires assistive device, but no other help or supervision.

Independent: no help, assistive devices or supervision required.

Mobility

Washing

Dressing

Feeding

Transferring

Continence

Details for correspondence and other contact; we may need more clarification and therefore contact you by phone.

Title

First name

Last name

Address including post code

Daytime phone **

Evening phone

Capital Care Financial Services Ltd is authorised and regulated by the Financial Services Authority.

Capital Care Financial Services Ltd is entered on the FSA register (http://www.fsa.gov.uk) under reference 435067.

** owing to the higher charges associated with mobile numbers we would be grateful if you could where possible give a land-line number.