Cumbria Mental Health Services
Supported Assessment Questionnaire
Resource Allocation System
Self directed support enables people who need social care and support
services to have greater choice and control over the services they receive.
We will use the resource allocation questionnaire to provide you with an
indication of how much money we could make available to pay for services
to meet these needs - this is called your indicative amount (IA).
Affix patient label
Forename:
Surname:
Date of Birth:
NHS Number:
Service User Demographics
Name
Address
Date of Birth
Contact Number
Ethnicity
Gender
Practitioner Details
Practitioner Name
Practitioner Team Name
Start Date of Assessment
Your Assessment
V0.12
12-12-2011
P
Affix patient label
Forename:
Surname:
Date of Birth:
NHS Number:
1 - Consent.
Have consent issues been discussed with the Service User?
Yes
No
Unable to give consent
If ”Yes”, was consent given for information to be shared as needed?
Yes
Yes, with limitations
No
Not applicable
Requested limitations for information sharing.
Please indicate below any limitations requested by the person
If the Service User is unable to give consent, please state why:
In some circumstances your local policy may enable you to continue with an
assessment without the Service Users consent. If you need to override
consent you must record a valid reason.
2
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record
Affix patient label
Forename:
Surname:
Date of Birth:
NHS Number:
Use the comment boxes below each domain to
clarify answers or to show if there is a difference in
view between Practitioner/Carer/Service User.
2 - MAKING DECISIONS AND HAVING CHOICE
This part is about how you decide the important things in your life – this could
include things like where you live, how and when you get to appointments or
the collection and management of medications. It may also include decisions
around how you occupy yourself throughout the day or how your money is
spent. You should consider whether you need support with making decisions
or do you need someone to make decisions for you?
DESIRED OUTCOME
I have the information and support I need to make choices that are right for
me.
STATEMENT – Please tick the box next to the
Tick the box that most clearly
statement that is closest to your situation
reflects the client’s independent,
unsupported
totallyability
Can achieve this outcome independently
Some support may be required in the future to
meet this outcome
Would occasionally like some support to meet
this outcome
Needs regular significant support to achieve this
outcome
Is unable to independently meet any aspect of
this outcome
Notes to support level of need indicated:
Care provided by a family
member, relative, neighbour,
friend or volunteer (unpaid
carer), providing practical
support, assistance and advice
to meet physical, emotional,
intellectual and social needs
0
3
¼
½
¾
Indicate who is providing the informal support: (optional)
All
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record
Affix patient label
Forename:
Surname:
Date of Birth:
NHS Number:
3 - DEVELOPING AND KEEPING RELATIONSHIPS AND INVOLVEMENT
IN ACTIVITIES
This part is about doing things in your community, like going to work,
accessing learning opportunities, using the local library, going to a club,
community centre, or a place of worship, visiting friends, or being involved in
local organisations
DESIRED OUTCOME
To be able to do the things I need to do to be a part of my community
STATEMENT – Please tick the box next to the
statement that is closest to your situation
Tick the box that most clearly
reflects the client’s
independent,
totally
unsupported
ability
Can achieve this outcome independently
Some support may be required in the future to
meet this outcome
Would occasionally like some support to meet
this outcome
Needs regular significant support to achieve this
outcome
Is unable to independently meet any aspect of
this outcome
Notes to support level of need indicated:
Care provided by a family
member, relative, neighbour,
friend or volunteer (unpaid
carer), providing practical
support, assistance and advice
to meet physical, emotional,
intellectual and social needs
0
4
¼
½
¾
Indicate who is providing the informal support: (optional)
All
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record
Affix patient label
Forename:
Surname:
Date of Birth:
NHS Number:
4 - DAILY LIVING TASKS
This part is about day to day life; things like shopping, cleaning, doing the
laundry, managing finances, paying bills, managing medications and
maintaining your home.
DESIRED OUTCOME
I am able to undertake routine daily living tasks including personal
care/domestic tasks and community activities.
STATEMENT – Please tick the box next to the
statement that is closest to your situation
Tick the box that most clearly
reflects the client’s
independent,
totally
unsupported
ability
Can achieve this outcome independently
Some support may be required in the future to
meet this outcome
Would occasionally like some support to meet
this outcome
Needs regular significant support to achieve this
outcome
Is unable to independently meet any aspect of
this outcome
Notes to support level of need indicated:
Care provided by a family
member, relative, neighbour,
friend or volunteer (unpaid
carer), providing practical
support, assistance and advice
to meet physical, emotional,
intellectual and social needs
0
5
¼
½
¾
Indicate who is providing the informal support: (optional)
All
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record
Affix patient label
Forename:
Surname:
Date of Birth:
NHS Number:
5 - PERSONAL CARE
This part is about looking after yourself – things like washing, dressing, and
going to the toilet
DESIRED OUTCOME
My Personal care Needs are met in the way that I want and with dignity and
respect.
STATEMENT – Please tick the box next to the
statement that is closest to your situation
Tick the box that most clearly
reflects the client’s
independent,
totally
unsupported
ability
Can achieve this outcome independently
Some support may be required in the future to
meet this outcome
Would occasionally like some support to meet
this outcome
Needs regular significant support to achieve this
outcome
Is unable to independently meet any aspect of
this outcome
Notes to support level of need indicated:
Care provided by a family
member, relative, neighbour,
friend or volunteer (unpaid
carer), providing practical
support, assistance and advice
to meet physical, emotional,
intellectual and social needs
0
6
¼
½
¾
Indicate who is providing the informal support: (optional)
All
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record
Affix patient label
Forename:
Surname:
Date of Birth:
NHS Number:
6 - EATING AND DRINKING
This part is about staying well nourished –including needing help or support
with prompting to eat or drink, or needing some assistance to prepare
DESIRED OUTCOME
My nutritional needs are met with respect for my choices.
STATEMENT – Please tick the box next to the
statement that is closest to your situation
Tick the box that most clearly
reflects the client’s
independent,
totally
unsupported
ability
Can achieve this outcome independently
Some support may be required in the future to
meet this outcome
Would occasionally like some support to meet
this outcome
Needs regular significant support to achieve this
outcome
Is unable to independently meet any aspect of
this outcome
Notes to support level of need indicated:
Care provided by a family
member, relative, neighbour,
friend or volunteer (unpaid
carer), providing practical
support, assistance and advice
to meet physical, emotional,
intellectual and social needs
0
7
¼
½
¾
Indicate who is providing the informal support: (optional)
All
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record
Affix patient label
Forename:
Surname:
Date of Birth:
NHS Number:
7 - PHYSICAL HEALTH AND WELL BEING
This part refers to help or support you might need to manage a long-term
health problem such as diabetes, heart or respiratory failure, liver problems,
stroke or epilepsy.
DESIRED OUTCOME
I have the help or support I need to manage or improve my physical health
and well being
.
STATEMENT – Please tick the box next to the
statement that is closest to your situation
Tick the box that most clearly
reflects the client’s
independent,
totally
unsupported
ability
Can achieve this outcome independently
Some support may be required in the future to
meet this outcome
Would occasionally like some support to meet
this outcome
Needs regular significant support to achieve this
outcome
Is unable to independently meet any aspect of
this outcome
Notes to support level of need indicated:
Care provided by a family
member, relative, neighbour,
friend or volunteer (unpaid
carer), providing practical
support, assistance and advice
to meet physical, emotional,
intellectual and social needs
0
8
¼
½
¾
Indicate who is providing the informal support: (optional)
All
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record
Affix patient label
Forename:
Surname:
Date of Birth:
NHS Number:
8 - MENTAL HEALTH AND EMOTIONAL WELL BEING
This part refers to help or support you may need with a mental health
condition such as acute anxiety, PTSD, schizophrenia, bi-polar affective
disorder, personality disorder, bereavement, dementia, depression or memory
loss.
DESIRED OUTCOME
I have the help or support I need to manage or improve my mental health
STATEMENT – Please tick the box next to the
statement that is closest to your situation
Tick the box that most clearly
reflects the client’s
independent,
totally
unsupported
ability
Can achieve this outcome independently
Some support may be required in the future to
meet this outcome
Would occasionally like some support to meet
this outcome
Needs regular significant support to achieve this
outcome
Is unable to independently meet any aspect of
this outcome
Notes to support level of need indicated:
Care provided by a family
member, relative, neighbour,
friend or volunteer (unpaid
carer), providing practical
support, assistance and advice
to meet physical, emotional,
intellectual and social needs
0
9
¼
½
¾
Indicate who is providing the informal support: (optional)
All
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record
Affix patient label
Forename:
Surname:
Date of Birth:
NHS Number:
9 - STAYING SAFE
This could be about your behaviour towards yourself and others. This could
also be about the support you need outdoors to help you stay safe or practical
indoor tasks such as using a cooker or using the stairs. It could be about the
risk to your general wellbeing if you need support to manage daily activities
around personal care, nutrition, health needs including intensive monitoring of
medications etc. Staying safe is different things to different people.
DESIRED OUTCOME
I am supported to make my own decisions and take risks that are acceptable
to me to live my life my way
STATEMENT – Please tick the box next to the
statement that is closest to your situation
Tick the box that most clearly
reflects the client’s
independent,
totally
unsupported
ability
Can achieve this outcome independently
Some support may be required in the future to
meet this outcome
Would occasionally like some support to meet
this outcome
Needs regular significant support to achieve this
outcome
Is unable to independently meet any aspect of
this outcome
Notes to support level of need indicated:
Care provided by a family
member, relative, neighbour,
friend or volunteer (unpaid
carer), providing practical
support, assistance and advice
to meet physical, emotional,
intellectual and social needs
0
10
¼
½
¾
Indicate who is providing the informal support: (optional)
All
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record
FACS ELIGIBILITY
Critical
Life is, or will be, threatened.
Serious abuse or neglect has occurred or will occur.
Significant health problems have or will develop.
There is, or will be, an inability to carry out vital personal care or domestic routines.
There is, or will be, little or no choice and control over vital aspects of the immediate
environment.
Vital family and other social roles and responsibilities cannot or will not be undertaken.
Vital involvement in work, education or learning cannot or will not be sustained.
Vital social support systems and relationships cannot or will not be sustained.
Substantial
Abuse or neglect has occurred or will occur.
Involvement in many aspects of work, education or learning cannot or will not be sustained.
The majority of family and other social roles and responsibilities cannot or will not be
undertaken.
The majority of social support systems and relationships cannot or will not be sustained.
There is, or will be, an inability to carry out the majority of personal care or domestic
routines.
There is, or will be, only partial choice and control over the immediate environment.
Moderate
Involvement in several aspects of work, education or learning cannot or will not be
sustained.
Several family and other social roles and responsibilities cannot or will not be undertaken.
Several social support systems and relationships cannot or will not be sustained.
There is, or will be, an inability to carry out several personal care or domestic routines.
Low
Involvement in one or two aspects of work, education or learning cannot or will not be
sustained.
One or two family and other social roles and responsibilities cannot or will not be
undertaken.
One or two social support systems and relationships cannot or will not be sustained.
There is, or will be, an inability to carry out one or two personal care or domestic routines
11
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record
12
Cumbria Mental Health Services
Supported Assessment Questionnaire
28/07/2017
Please file the completed form in section 3C of the Integrated Health Record