Online Application Form

Once we receive your completed application form, we will contact you to confirm you have been placed on the waiting list. We may contact you if we require clarification on anything on the application form. We will not carry out a full assessment of your needs until a suitable place becomes available in the care home of your choice.

It is important you let us know of any changes in circumstances that may affect the application, particularly the contact details.

Section A: Personal Details of Prospective Resident

Forename *

Surname *

Martial Status *

Date of Birth *

NI Number *

Telephone *

Home Address *

Limit 1450 characters

Current Address *

Limit 1450 characters

Section B: Care Requirements

Which of the following homes would you prefer? *

St Raphael's
Marian House
Lennox House

How soon would you like to move into a care home? *

As soon as possible
1-3 months
6 months
1 year

Section C: Income

Does anyone have legal responsibility for dealing with your finances? *

Yes
No

Please note it is necessary to provide evidence of income and capital/assets along with this application i.e. a letter from your solicitor/financial advisor or Power of Attorney.

State Pension p/w *

Attendance Allowance p/w *

Occupational Pension p/w *

Other Income p/w *

The total value of your assets (including the value of your home). *

We need to know about your income and ability to meet the fees. Whilst we can accept applications from people who cannot meet the fees themselves and are eligible for assisted funding from the Local Authority, we can only accept a restricted number of people into our care homes on this basis. This is due to the fact that currently the level of assisted funding from the Local Authority does not meet the actual costs of providing the service. A place will be offered in the first instance to those who can meet the room fees from their income, or to existing Viewpoint tenants. We require evidence that an applicant has sufficient income to meet the room fees for a 3-year period. Your solicitor or your bank or someone who has responsibility for your finances such as a Power of Attorney can provide evidence.

Section E: Personal and Nursing Care Funding

Have you applied to the Local Authority for an assessment to establish if you qualify for funding towards free personal care and or nursing care? *

Yes
No

This section relates to funds, which are available under the Health and Community Care Act 2002—this is separate from what is known as assisted funding and is not means tested. The funds are administered by your local social work centre and they must assess your needs to establish if you will qualify for the funding. This money is paid directly to Viewpoint and is deducted from the room fees leaving you to pay the balance. If you are currently in receipt of Attendance Allowance, this will cease if you start to receive free personal and/or nursing care funding. It is advisable to speak to your local social work centre about applying for the funding at the same time as making this application to Viewpoint to allow time for the assessment to be carried out. Please note that we cannot hold a room vacant on the basis that an assessment for free personal or nursing care funding has not been carried out.

Section F: Emergency Contact Details

Next of Kin/Emergency Contact Name

Next of Kin/Emergency Contact Telephone Number

Next of Kin/Emergency Contact Email

Next of Kin/Emergency Contact Address

Limit 1450 characters

Power of Attorney Name

Power of Attorney Telephone Number

Power of Attorney Email

Power of Attorney Address

Limit 1450 characters

Lawyer Name

Lawyer Telephone Number

Lawyer Email

Lawyer Address

Limit 1450 characters

Doctor Name

Doctor Telephone Number

Doctor Email

Doctor Address

Limit 1450 characters

Social Worker Name

Social Worker Telephone Number

Social Worker Email

Social Worker Address

Limit 1450 characters

We ask you to supply contact names for emergencies.

Section G: Declaration

Are you related to any Viewpoint Board member, an employee, or anyone who held such a position within the last 12 months? *

Yes
No

Would you like us to contact someone else about this application on your behalf? *

Yes
No

How did you hear about us? *

Your Name *

Your Relationship to the Prospective Resident

Date *

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