East Sussex Pilot SAQ; TASC Questionnaire (pdf - 512Kb)

In-Control (Health) Pilot
Self-directed Assessment
Questionnaire (SAQ)
The project is for people in need of day and vocational services who have a
recognised mental health diagnosis. They must have „substantial‟ or „critical‟
needs and be working age (over 18yrs and under 65 yrs).
Why should I complete this form
The information you provide will be used to decide whether you are eligible
for these services and how much your individual budget allocation will be.
You can complete this form yourself or with help from people you trust –
your family, friends, carer, care co-ordinator or someone who knows you
well.
Please complete this form as fully and clearly as possible.
Need help to complete this form
If you need help to complete this form you can ask someone to help you or
contact Kenny Mackay at 01323 747223.
East Sussex County Council
Adult Social Care Department
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K Mackay In-Control Pilot (Health) – V2

Completing your questionnaire
Please follow these points:
It‟s up to you whether you complete your questionnaire on your own,
with your carer, or with friends and family.
Please be honest. Please complete the questionnaire as fully as
possible.
Please tick in the column „What I think‟, Your Care co-ordinator will
complete the next column, shaded in light grey and the final decision
and point‟s allocation will be completed by East Sussex County
Council. These columns are shaded in yellow.
Please tick the statement that best describes your situation. If you do
not agree with any of the statements in a question or do not find them
applicable to you please tell us why. Our contact details are on the
front page.
If you do not understand any of the questions, please do not hesitate
to ask the person who gave this questionnaire to you who will try and
answer your question.
For each question, there are points allocated to the answer. These
will be used to help us work out how much money you should be
offered in your personal budget.
Please only complete the „What I think‟ section. Your Care coordinator
will complete the next section. If their answers are different
to yours, they will discuss the reasons with you to eventually reach a
final score.
If you do not complete this questionnaire, you will not be able to receive an
Individual Budget.
An Individual Budget will not affect any benefits that you receive or affect
your or your carer‟s eligibility status.
What happens next
After you have completed your questionnaire, please return it to the person
who gave this questionnaire to you. You will then be contacted to let you
know if you are eligible for an Individual Budget and how much you will get.
East Sussex County Council
Adult Social Care Department
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East Sussex County Council
Adult Social Care Department
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Your reasons for contacting us.
Please tell us about any difficulties you are experiencing
Please tell us about your personal background and the
relationships you most value
(Continue on a separate sheet of paper if necessary)
East Sussex County Council
Adult Social Care Department
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1. Day-to-day activities
Please indicate the support you require to complete the practical day-to-day activities that
“keep the wheels turning” in everyday life (e.g. shopping, cleaning and tidying your home,
cleaning up after meals, doing laundry paying bills, dealing with letters and forms).
What I need My View CC View Agreed View Score
A = I complete these activities
without any need for support and
assistance.
B = I need occasional support or
assistance about once a month.
C = I need support and assistance
about once a week.
D = I need support and assistance 2
or 3 times a week.
E = I need support or assistance on
a daily basis.
How would you like your situation to change for the better What would make the
most difference to you
East Sussex County Council
Adult Social Care Department
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2. Planning and organising your daily life
Please indicate any assistance that you need in planning and organising your daily life.
This might include managing your finances, arranging support, making arrangement for
repairs to your home or property, appointments, travel or holiday.
What I need My View CC View Agreed View Score
A = I complete these activities
without any need for support or
assistance
B = I need occasional support or
assistance about once a month.
C = I need support and assistance
about once a week.
D = I need support and assistance 2
or 3 times a week.
E = I need support or assistance on
a daily basis.
Do you manage your own finances If no then please tell us who does.
Yes No
How would you like your situation to change for the better What would make the
most difference to you
East Sussex County Council
Adult Social Care Department
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3. Spending time with other people
Please indicate the extent to which you need support to enable you to spend more time
with other people. This might include meeting new people, making new friends or simply
spending more time in the company of others.
What I need My View CC View Agreed View Score
A = I do not wish to spend more time
with other people – I am happy with
how things are.
B = I spend some time with other
people but would like to spend more
time or have more opportunities to
meet people and form relationships.
C = I spend very little time with other
people and would like more
company and more opportunities to
meet people and make new
relationships.
How would you like your situation to change for the better What would make the
most difference to you
East Sussex County Council
Adult Social Care Department
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4. Your involvement in work, training and education.
Please indicate those aspects of work, training or education that you wish to become
involved with or need support to maintain your existing involvement.
Work may include either paid or voluntary work. Education and learning could involve
studying for a qualification or simply attending a local class about something that interests
you.
What I need My View CC View Agreed View Score
A = I need support to enable me to
access employment opportunities.
B = I need support to enable me to
maintain my existing employment
situation.
C = I need support to enable me to
access learning, educational or
training opportunities.
D = I need support to enable me to
maintain my existing involvement in
learning, educational or training
opportunities.
How would you like your situation to change for the better What would make the
most difference to you
East Sussex County Council
Adult Social Care Department
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5. Your involvement with the community.
Please indicate the support you need to enable you to do things in your local community
such as cinema, clubs, restaurants, parks and shops.
Please let us know if you need support accessing your preferred place of worship or
accessing any of your spiritual needs.
NB: (You can tick one or more of the following statements)
What I need My View CC View Agreed View Score
A = I need support to enable me to
access leisure opportunities such as
the cinema, restaurants or local
shops.
B = I need support to enable me to
access my preferred place of
worship.
C = I need support to enable me to
be more involved in my local
community (e.g. sporting activities, or
other local organisations clubs or
events.
In a typical week on how many occasions do you need support for such activities (If on
some days you would like to get out more than once then count this as two occasions
rather than one.)
Details:
How would you like your situation to change for the better What would make the
most difference to you
East Sussex County Council
Adult Social Care Department
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6. Your emotional well-being and mental health.
Please indicate how you feel day to day at present.
What I need My View CC View Agreed View Score
A = I am usually happy and rarely
or never feel tense low, miserable
or worried.
B = I am generally happy but
occasionally feel low, miserable,
tense or worried.
C = I am generally happy but
sometimes feel low, miserable,
tense or worried. This sometimes
makes it harder for me to get on with
my life.
D = I frequently feel low and
miserable, tense or worried. This
often makes it hard for me to enjoy
or get on with my daily life.
E = I feel low, miserable, tense or
worried most or all of the time.
This generally makes it hard for me
to enjoy or get on with my daily life.
Have you seen or been advised to se a counsellor or mental
health professional in the recent past.
Have you ever been diagnosed as suffering from a mental
illness such as depression or schizophrenia
Yes
Yes
No
No
How would you like your situation to change for the better What would make the
most difference to you
East Sussex County Council
Adult Social Care Department
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7. Your carers support needs
Please give details about the person who provides you with your main elements of
support. Please indicate whether providing you with support is having an impact on your
carer‟s ability to lead their everyday life. If there is no main person that gives you this
support please leave this section blank.
Who is your main carer
What I need My View CC View Agreed View Score
A = My carer is able to live their life
a normal life and my needs don‟t
affect them to a significant degree
B = My carer is able to do most
things but providing me with support
does affect them to some degree.
C = My carer has had to reduce
some of their activities or spend less
time with other people in order to
support me.
D = My carer has had to reduce
many of their activities or spend
much less time with other people in
order to support me.
E = My carer spends most of their
time with me and has little or no time
to carry out their own day-to-day
living.
How would you like your situation to change for the better What would make the
most difference to you
Has your carer been offered a recent carer‟s assessment (in
the last six months)
Yes
No
East Sussex County Council
Adult Social Care Department
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Statement around risk
Please give an honest statement regarding your risk. This should be around
vulnerability, self neglect or self harm.
Your care co-ordinators view
Name:
Signature:
Date:
East Sussex County Council
Adult Social Care Department
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East Sussex County Council
Adult Social Care Department
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Thank you for completing this form
Please confirm that:
You are over 18 years of age or if you are caring for a person
you are over 16 years of age.
That you or the person you are caring for lives within our local
authority East Sussex.
You are aware that the information you are providing to us may be
used or shared with relevant parties, family or organisations to enable
us to help assist your needs.
That information held will be stored electronically in a secure and
confidential Health and Social Care Records.
That if the information provided to us indicates any evidence of risk of
self harm or harm to others or in the community, we may take the
appropriate action in accordance to our duty of care as a local
authority.
You are aware that we can not guarantee that any service or
equipment selected within the assessment is available; however East
Sussex Adult Social Care will help support and assist you in finding
alternative options.
That you can confirm that you have read the eligibility criteria.
to
By ticking this box you are confirming that you understand and agree
the above terms and conditions.
Your signature
Date
Please return this form to:
Kenny Mackay, Project Manager, In-control
St Mary‟s House, St Leonard‟s Rd, Eastbourne, Sussex, BN21 3UU
East Sussex County Council
Adult Social Care Department
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For office Use only
Date Form Sent: / /
Surname:
ID Ref Number: P
Date Received: / /
Authorised by:
Comments:
Specialist
Assessment
Required
OT
Mental health
Blue Car Badge
Financial Assessment
East Sussex County Council
Adult Social Care Department
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