Lifeline “Peace of Mind” Service

Name :

Email :

Telephone :

Mobile :

Date of Birth :

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Do you live outside borough :

Address Details :

Key Safe Number: (Please phone us if you would like information about a Key Safe) :

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Do you live alone? :

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In your own words why do you think you would benefit from a Lifeline Telephone? :

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Are you prepared to meet the weekly monitoring and service charge? :

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Do you have the ability to understand and communicate effectively? :

General Medical Information :

Additional Information / Special Instructions/Referrals: (Access Details) :

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GP Name :

GP Telephone Number :

GP Surgery Address :

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Home Care (Local Authority/Private Organisation) :

Home Care Telephone :

Home Care Address :

Details of Support Received e.g. Which days do they Visits? :

What time does Home Care arrive? :

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Nominated Contacts :

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Are you filling in this form on behalf of the applicant? :

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Fees

Fee Type :

Fee Cost : £