Find out if you, or someone you know, may have care needs which qualify for support from us.
You may qualify for help if you are not able to do certain things that affect your wellbeing. These may include:
- washing yourself
- getting dressed
- going to work, college or volunteering
- keeping your home safe for you to live in
You can complete this form for yourself, on behalf of someone else or with support from someone else. If you are unable to fill out our online form or do not have someone who can help you, please contact us.
Part 1 will ask you some quick questions about your situation. At the end of this, we will tell you whether we think you may benefit from a conversation with us. We will also give you with information and advice based on your answers.
If you want to carry on, you can choose to complete part 2 of the form. In this part, we will ask you for more detailed information about yourself and your situation.
Before you start
You must:
- be an adult over 18
- give permission to store information about you
- live in Ealing borough
If you or someone else is in danger or there is an emergency, phone the police on 999, or call them on 101 if it is less urgent.
If it’s urgent, call social services on 020 8825 8000 (adults’ option) to talk about the referral.
Care and support the council arranges is not free. The amount you pay will depend on the level of care you need and how much money and property you have.
You will need
- who (if anyone) you would like to be involved in your assessment. If you have a carer then we will need to speak to them
- what you are finding difficult and how this is affecting you in your daily life
- looking after yourself (for example: washing, dressing, meals, shopping, managing your home and finances)
- support already available to you – what’s working well (for example: help from family and friends, equipment and aids, paid carers)
- if you are a parent or carer, how your caring role affects you day to day
- information on any difficulty with daily activities and mobility
- explanation of your situation or recent changes
- NHS number
- Mosaic reference number (if you have one)
- Type of benefits you get
What happens next
We will review all referrals within 2 working days and get in touch with the person needing support within 6 weeks.
After the assessment, we will email you and explain our decision.
If you qualify for help, we will work with you to plan your care and support. We will look at different types of support to help you maintain or get independence.
If you do not qualify for help, we will give you information and advice about available care and support.
Filling in the form
The form cannot be saved and each page will time out after 20 minutes. If you think you will need more time, prepare your answers before you start the form. This helps make sure your information is not lost.
Copying and pasting answers into a form can cause an error. If pasted from Microsoft Word or PDF, these characters may show an error -.,'"£#:;=/\()?&+@!