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About Us
- Healthy Living Articles
Places We Work
Commissioners
- NHS Professionals
Private Services

My Life Plan Login

LD Form

LD Referral Form

Step 1 of 11

9%

About Me

Full Name(Required)

First

Date of Birth(Required)

Day

Month

Year

Gender(Required)

Male

Female

Other

Prefer not to say

Please write in the box below

Address(Required)

Street Address Town/City Post Code

Home Phone Number

Mobile Phone Number

Email Address(Required)

My Learning Disability

1. Do you have a learning disability?

If you do not know, leave the box blank.

My Communication

2. The language I speak and understand is:(Required)

3. How do you communicate?(Required)

Tick as many as you like.

Image for choice number 1

Talking

Image for choice number 2

Signing

Image for choice number 3

Using a communication aid

Image for choice number 4

Pointing and gestures

4a. Do you have any difficulty in communicating?(Required)

Yes

No

4b. What helps you to communicate?(Required)

My Diet

5a. Do you have any difficulties eating, drinking or swallowing?(Required)

Yes

No

5b. What helps you eat, drink or swallow?(Required)

5c. Do you see a speech therapist about this difficulty?(Required)

Yes

No

Weight & Appetite

6a. Are you worried about your weight?(Required)

Either putting on too much weight or losing weight.

Yes

No

6b. Why are you worried about your weight?(Required)

Please write in the box below.

My Mobility

7. Are you able to move around easily?(Required)

Yes

No

8. Any comments about your mobility?

9a. Do you use mobility aids?(Required)

This includes wheelchairs, walking sticks, crutches, walkers or a frame etc.

Yes

No

9b. If yes, what mobility aid(s) do you use?(Required)

My Hearing

10. Do you have any difficulty hearing?(Required)

Yes

No

11a. Do you have a hearing aid?(Required)

Yes

No

11b. If yes, do you wear it?

Yes

No

Sometimes

My Eyesight

12. Do you have any problems with your eyes or difficulty seeing things?(Required)

Yes

No

Epilepsy

13a. Do you have epilepsy?(Required)

Yes

No

13b. If yes, do you know what kind of epilepsy you have?(Required)

Any Other Health Conditions

14. Do you have any other health conditions?

If you don’t, leave the box blank.

My Mental Health

15. Do you feel anxious or worried a lot of the time?(Required)

Yes

No

16. Do you feel sad for long periods of time and find it difficult to cheer yourself up?(Required)

Yes

No

17. Do you get angry and shout at people a lot?(Required)

Yes

No

18. Do you ever try to hurt yourself?(Required)

Yes

No

19. Do you see a psychiatrist?(Required)

This is someone who specialises in the prevention, diagnosis, and treatment of mental illness.

Yes

No

20. Do you have support from the mental health team?(Required)

Yes

No

21. Do you have any other comments about your mental health? If not then leave blank

My Care & Support

22. If you have support, who supports you?

If you don’t have any support, skip to forward to question 28.

23. Will they be attending with you?

Yes

No

24. Will they be attending for you?

Yes

No

Family

Name of family carer

First

Family carer’s contact number

Family carer’s e-mail address

Paid Support Worker/Carer

Name of support worker or carer

First

Support worker’s phone number

Support worker’s e-mail address

Social worker (if you have one)

Name of social worker

First

Social worker’s contact number

Social worker’s e-mail address

My Care and Support to Others

25a. Are you a carer for anyone?(Required)

This could be for children, parents or a partner.

Yes

No

25b. If yes, who do you care for?(Required)

Any other information

26. Is there anything else you would like to tell us?

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