ARROW Consultation Booking & Information Form

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ARROW In-Person Consultation Booking Form

Thank you for purchasing ARROW’s In-Person CHC Eligibility/ Assessment Preparation Review

Step 1:

Please complete the form below before booking your consultation. The information you provide will help ARROW prepare for the discussion and ensure that the consultation time is used as effectively as possible.

Once you have submitted the form, please use the Calendly booking system below to arrange your consultation.

Your Name *

First

Last

* Indicates required field

Your Email *

Your Phone Number *

Name of person requiring assessment *

First

Last

Date of Birth of Person Requiring Assessment *

DD/MM/YYYY

What is your relationship to the patient? *

Please select from the drop down menu

If 'other' please state: *

What county is the patient currently permanently resident in? *

Enter county

Do you hold Lasting Power of Attorney or a Deputyship Order for the patient? *

Yes No Other

If 'other' please explain below: *

Has a CHC Checklist already been completed? *

Current CHC stage *

Considering CHC Checklist requested Positive Checklist Awaiting DST DST Completed Review Appeal Retrospective Claim Unsure

Do you have any of the following documents available? *

Please upload any documents you would like to be considered before the consultation. *

Max file size: 20MB

Please note that this service does not include a comprehensive review of medical or care records. The purpose of any documents provided is to assist preparation for the consultation and written report.

Does the patient have difficulty with or require help with any of the following? *

Breathing Eating Toileting Skin integrity e.g. pressure sores Mobility Communication Psychological and Emotional Needs Cognition e.g. dementia Challenging behaviour e.g. aggression or resisting care Managing pain and taking medication Dizziness, blackouts, mini strokes Other (please describe below)

Please select all that apply

If 'other' please describe: *

Does the patient require 24-hour care? *

Yes No

Where is the patient currently being cared for? *

In residential care In hospital At home In hospice care Other

If 'other' please state: *

Please provide a brief summary of the patient’s health needs and the care required to address them. The more detail you are able to provide, the better. *

The data I submit will be collected and processed in accordance with ARROW’s Privacy policy. I understand that it will not be used for any purposes other than those specified. *

Yes

Submit

Step 2:

Please book your consultation using the calendar below:

ARROW Continuing Healthcare Consultants
Proprietor: Dr Ros Setterfield: PhD in Law; PGDip (Legal Studies); BA (Hons)

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