Family or Private Care Enquiry – Controlled Replacement (QMS-F038A) Family or Private Care Enquiry - Controlled Replacement (QMS-F038A) Notify FAMILY OR PRIVATE CARE ENQUIRYQMS-F038A | Version 1.0.0 | CONFIDENTIAL - Enquiry RecordPurpose: Collect only the minimum information needed to contact the enquirer, confirm basic service fit and arrange a human response. A Service User ID is not allocated at this stage.Not an emergency service. Call 999 where someone is in immediate danger or needs urgent emergency assistance. Do not include unnecessary medical records, passwords, bank details or identity documents.SECTION 1: ENQUIRER AND SAFE CONTACTEnquirer Full NameWho Is the Enquiry For?- Select -MyselfMy spouse or partnerMy parentMy grandparentAnother family memberA friend or neighbourA person I support as an unpaid carerOtherSafe Preferred Contact Method- Select -TelephoneEmailText messageNo preferenceEmail AddressTelephone NumberSafe Times or Contact RestrictionsSECTION 2: PERSON AND LOCATIONPerson's Name or InitialsIs the Person Aged 18 or Over?- Select -YesNoUnsurePostcodePrimary Area- Select -HaringeyIslingtonBarnetWaltham ForestEnfieldCamdenHackneyOther nearby London areaOutside current operating areaNot yet confirmedCurrent Setting- Select -Own homeFamily or friend's homeTemporary accommodationHospital - information only, discharge planning requiredResidential or nursing setting - transition enquiryOtherNot yet confirmedSECTION 3: SUPPORT SOUGHTWhat Support Is Being Considered? Personal Care and hygiene Dressing and grooming Toileting or continence support Meals, nutrition or hydration support Mobility or transfers Medicines prompting or support Dementia or cognitive support Companionship linked to Personal Care Respite or short-term Personal Care End-of-life Personal Care support OtherBrief Summary of What Matters and the Support Being SoughtWhen Might Support Be Needed?- Select -Information onlyWithin 24 hours - urgent human triageWithin 2 to 3 daysWithin 1 to 2 weeksMore than 2 weeksNot yet knownFunding Position- Select -Local Authority commissioned careDirect Payment or personal budgetNHS Continuing HealthcarePersonal Health BudgetJoint Local Authority and NHS fundingPrivate or self-fundedMixed fundingFunding not yet confirmedOtherSECTION 4: IMMEDIATE INFORMATION AND CONSENT TO CONTACTIs There an Immediate Safety or Safeguarding Concern?- Select -NoYes - human response requiredUnsureBrief Safety ConcernIs the Person Aware of This Enquiry?- Select -YesNo - explainUnsureI am enquiring for myselfExplanation Where the Person Is Not AwareConfirmation I confirm the information is accurate to the best of my knowledge and I agree that Mutima Care may contact me about this enquiry.case_idcase_refservice_user_idstage_tokensource_entry_idsubmission_stagedocument_refrecord_versionprovider_statustest_record
