Care Solutions Questionnaire

To recieve your FREE, no obligations care fees report please complete the following questions as fully as possible.
Don't worry if you are unable to answer some of them, we will still be able to send you a report.

Your Objectives - What would you like to provide for?

Please state the amount you have been quoted to provide for long term care. If you have not yet received a quotation, then leave blank and we will base the cost on the average in you area.

COST PER WEEK £

Details of individual(s) for whom care is to be provided.

Care Recipient

Title:

Name:

Date of birth / 

Day:

Month:

Year:

If you are completing this form on behalf of an elderly person, please state your relationship. E.g. daughter, nephew, friend, etc.

Do you hold an Enduring Power of Attorney?

Financial details of care recipient

Income
STATE PENSION £
PRIVATE PENSION £
ATTENDANCE ALLOWANCE £
OTHER £

Assets
MAIN RESIDENCE £
OTHER PROPERTY £
BANK / BUILDING SOCIETY £
NATIONAL SAVINGS £
ISAS / PEPS / UNIT TRUSTS / SHARES £
TESSA's £
OTHER INVESTMENTS £

Amount

Amount