Care Act Assessment Eligibility Checker

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Ready? Enter your details:

We will ask you several questions about you or someone you represent. This form takes just a few minutes to complete.

Your answers will determine your eligibility for a Care Act assessment. Please read our Privacy Policy to understand how we protect your data.

Note:- * Fields are mandatory
Whom are you completing this tool for?*

Title*

First Name*

Last Name*

Email*

Age*

 18+  

 Below 18

Which Council do you pay your Council Tax to?*

Background Information:

0/200

1) Do you or the person you care for face challenges due to a Long-term condition or a disability?*

YES

NO

If Yes, please select below:
Physical Disability  
Learning Disability  
Sensory Impairment  
Frailty  
Substance Misuse  
Mental Health  
Dementia  
Other  
2) Do you or the person you care for experience significant difficulties managing or maintaining your well-being?*

YES

NO

If yes, select from the below list?
Nutritional needs
Personal hygiene
Toilet needs
Appropriately clothed
Habitable home environment
Developing and maintaining relationships
Participating in work, training, education, or volunteering
Accessing local services
Caring responsibilities for a child or any other person.
Able to make use of your home safely.
Do you want upload Supported Documents?*

 Yes  

 No

Privacy Policy

This form collects your name, email, and other personal information. This confirms that you are an ordinary resident of the local authority from which you may require support.

Please note: Your data will be used solely for eligibility checks and safely deleted from our servers after your results are published. The same result will be sent to the email ID you entered. For privacy reasons, this form will not store your details on our servers.

Your consent *

  I consent to the FYS team collecting and accessing my data from this form for eligibility check purposes.