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Self Assessment Form

Further Information

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Eligibility

This form is only for those who live in the County of Leicestershire.

This form is to be completed if you feel that you would benefit from small items of equipment or minor adaptations in your home and would like to achieve this through a self assessment.

Some minor items of equipment and minor adaptations can be provided and are free of charge if you are eligible for them. We need to ask a number of questions that will help us to consider if we can proceed with issuing equipment or whether we need to carry out further assessments. Please give as much detail as possible including measurements where requested. This information section will be considered by an Occupational Therapist. If you are unclear about any of the questions please contact the Customer Service Centre.

This form can be saved, meaning you do not have to complete it in a single attempt but can return and complete it at a later time. Please note that an Email Address is essential for saving your form. Help with saving your online Self Assessment Form.

Self Assessment for Equipment and Minor Adaptations

Please Note: Fields marked with an Asterisk (*) are required.

SSIS reference number

I have difficulties with: ^* Please tick those that apply.

Using the toilet
Commode
Bathing
Using the steps
Using the stairs
Bed
Seating
Preparing food in the kitchen
None of these, please contact me to discuss my needs

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