Immediate Care Plan ~ Quick Illustration

How much might a care plan cost?

Complete the form below to request an illustration.

If you need help completing this form call 0800 078 7430 or use our guide.

Click here for our care funding calculator. 

All links in the main body of this page open in a new window so that the information entered into the form is not lost.

All information is treated in the strictest of confidence

 

Care Plan ~ Quick Illustration Please complete your information below for a care plan illustration
Please complete your contact details
Title	Mr Mrs Ms Dr Rev Sir
First Names *
Surname *
Address *
Postcode *
Phone Number *
Email *
How did you hear about the Care Fees Advice Agency?	search engine leaflet in a care home recommendation National Careline advertising link from Symponia website other
If you are not the person requiring care, please complete the following section
Title (person requiring care)	Mr Mrs Ms Dr Rev Sir
First Names (person requiring care)
Surname (person requiring care)
Why are you enquiring on behalf of this person?	I hold a Lasting Power of Attorney I hold an Enduring Power of Attorney I hold a General Power of Attorney I am their Deputy They have asked me to
What is your relationship to the person in care?	e.g. mother, brother, wife, friend etc
All applicants should complete the following questions
Sex (of person requiring care)	male female
Date of Birth (of person requiring care)
Care Type	residential care nursing care care at home EMI residential care (dementia) EMI nursing care (dementia)
Date moved into care	Enter a future date or ’shortly’ if date not yet known
Financial Details For the person requiring care
Income per week £ including state benefits
Total assets £ including any property value
How much are the care fees £ (per week)
Monthly Income required £ (care plan benefit)
Below are nine questions about your health (or the health of the person about whom you are enquiring). Please answer them as accurately as possible. Please indicate whether you suffer from any of the following conditions.
1. Dementia
Degree of dementia	none   mild   moderate   severe
Type	Multi-Infarct / Vascular   Alzheimers type   other
When were the symptoms first noticed?
When was care for dementia first required?
2. Stroke
Stroke	none   history of mini-strokes (TIA’s)   mild stroke   moderate stroke   severe stroke
When was the last incidence?
3. Joint Disorder
Arthritis /Joint Disorder	none   mild   moderate   severe
Type (tick all that apply)	Rheumatoid / Osteoarthritis   Osteoporosis   Joint replacement   other
4. Heart or Circulatory Disease
Heart or Circulatory Disease	none   mild   moderate   severe
Type (tick all that apply)	Heart Attack   Angina   Hypertension (high blood pressure)   Valve Disorder   Heart Failure   Other (please specify below)
Other
5. Neurological Disease
Neurological Disease	none   mild   moderate   severe
Type (tick all that apply)	Parkinson’s Disease   Multiple Sclerosis   Motor Neurone Disease   Other (please specify below)
Other
6. Respiratory Disease
Respiratory Disease	none   mild   moderate   severe
Type (tick all that apply)	Bronchitis   Pneumonia   Emphysema   Athsma   Other (please specify below)
Other
7. Cancer
Cancer - please give details and dates
8. Additional Information
Do you feel that you have deteriorated physically over the past six months?	little or no deterioration   moderate   significant
Other information: Please tick these boxes if	you permanently require the use of a wheelchair inside and outside all day   you have suffered a fall in the past six months   you are confined to bed
Medication (if known)
Please enter details of anything else significant or expand on the answers to questions above.
9. Activities of Daily Living Please give details of your ability to perform the following activities. The level of assistance is classified as follows: Major - Always require both assistive devices and some personal assistance Moderate - Requires assistive device and some personal assistance Minor - requires assistive device but no other help or supervision Independent - No help, supervision or assistive device required
Mobility	independent requires minor assistance requires moderate assistance requires major assistance
Washing	independent requires minor assistance requires moderate assistance requires major assistance
Dressing	independent requires minor assistance requires moderate assistance requires major assistance
Feeding	independent requires minor assistance requires moderate assistance requires major assistance
Transferring	independent requires minor assistance requires moderate assistance requires major assistance
Continence	independent requires minor assistance requires moderate assistance requires major assistance
Please click submit for your quick care plan illustration By submitting this form you are authorising the Care Fees Advice Agency to hold and use the information provided for the purposes of obtaining an illustration for an immediate care plan. If you are enquiring on behalf of somebody else you are also confirming that you are authorised by them to provide the information given. You confirm that you have read and understood our data protection policy (link below)
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We trust that you will find carefeesadvice.com useful and informative. We have made every effort to ensure that the information contained is clear, up to date and accurate. However, nothing on this site should be relied upon when making care or financial decisions, nor should anything on this site be regarded as financial advice. Our care fees planning service can provide you with specific help and specialist, care based, independent financial advice. By proceeding through this site you accept that carefeesadvice.com, the Care Fees Advice Agency and Financial Care Consultants Limited cannot be held responsible for any actions you take as a result of the information held on carefeesadvice.com. All information given relates to England. Whilst most of the principles remain the same, some benefits and benefit levels are different in Scotland, Wales and Northern Ireland. We are happy to provide details for these regions on request.

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The Care Fees Advice Agency is a trading style of Financial Care Consultants Limited of Unit 2, Timberlaine Trading Estate, Decoy Road, Worthing, West Sussex, BN14 8ND, which is authorised and regulated by the Financial Services Authority. Our FSA registration number is 530883 and you can confirm our authorisation by checking the FSA register.

 

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