Care and Support Needs Assessment Contact Form

Our teams are here to help you with each step of finding and arranging the right care for you or your loved one. We provide this support in partnership with the Royal Borough of Windsor and Maidenhead.

Complete the form below and we will get in touch with you shortly.

Please note that we do not manage referrals for:

Mental health - click here to visit the Berkshire Healthcare NHS Foundation Trust and make an adult mental health referral
Substance misuse - click here to visit Cranstoun, the adult alcohol and drug service in the Royal Borough of Windsor and Maidenhead.

This form should be used for anyone living in the Royal Borough of Windsor and Maidenhead area, who requires help and support from our Adult Social Care Teams.

Please note that Optalis will treat your information confidentially. Visit our privacy statement page for more information.

If you have any concern that a vulnerable adult living in Royal Borough of Windsor and Maidenhead may be at risk of harm or neglect, please contact the Front Door Team in Social Care Services straight away on: 01628 683744 or emergency out of hours on: 01344 351999.

If the person who requires support lives in Wokingham, please visit their Adults Social Care information page.

First Name (of person being referred or assessed)

Last Name (of person being referred or assessed)

Date of Birth

NHS number (if known)

Address (including postcode)

Phone Number

Do you pay council tax to Windsor and Maidenhead Council?

Yes

Who is completing this form? (If not applicant relationship and contact details)

Next of Kin details

GP practice details

Do you give us consent to use and share your data?

Yes

Relevant medical history & conditions that impact your Independence*

Have you had any recent hospital admissions? If yes, for what reason & when were you discharged?

What support, if any do you currently have available to you?

Is there a social care package in place? If so, please state provider. What other ‘informal’ support is available / currently being provided

Who is funding any support receive?

Please tell us briefly why are you contacting us?

Please include details about your situation and how long you have been experiencing any challenges, how can we help, any relevant disabilities or medical diagnoses, any communication needs, anything else you think we should be aware of.

Additional comments:

(Please include any information relevant to the current situation, best person to contact, sensory needs for communication, challenging behaviour, IDENTIFY ANY RISKS)

Please specify the best way to communicate with you.

Telephone

Other

If other, how you would like to be contacted