Are your contact details correct? What PB service are you interested in?

The PB team is currently updating details of people who use our service. If you currently use the ADKC Personal Budget Service, or would like to, please fill in the form below and email it to pbadmin@adkc.org.uk or post it to us at the office.

Personal Budget User Group – Information Sheet

Name:

Are you still in receipt of a personal budget from RBKC?  Yes / No

If no – do you pay out of your own money to have help due to you being disabled?                                                                 Yes / No

(If NO to both – thank you for your time)

(If YES to either – Please continue down the page)

Address:

Postcode:

Home phone:

Mobile Phone:

Email:

Preferred method of contact: Phone / Email / Post / Text / Other

Preferred method to receive notice of meetings, minutes and/or newsletters:              Post / email

Access requirements: Standard, Large print (font size _________),          Font /Paper colour _____  ______, Braille, Audio, Wheelchair access, Hearing loop, Other _____________________________________

Date of Birth:

Ethnic background:

Impairment type: Physical / Sensory / Hidden / Mental health / Learning disability / Long term health condition / other ___________

Are you currently a member of ADKC?      Yes / No

(If they have a physical /sensory impairment and are under 60 ask if they would like to be a member                    Yes /No

Are you interested in any of the following:

·        Attending monthly PB user group meetings:             Yes / no

·        Promoting the PB service to other people:                           Yes / No                                                                                  

·        Attending small groups focussing on specific issues:               Yes / No

·        Helping to compile/edit the quarterly PB newsletter:   Yes / No                                                                                      

·        Helping to develop a PB website /resource library:      Yes / No

·        Providing peer support / mentoring:                            Yes / No

·        Designing help sheets:                                                   Yes / No

Would you like to receive further training about any aspects of personal budgets meeting for example:

·        Finances (what records to keep, filling in the financial monitoring forms etc)                                                   Yes / no

·        Recruiting private workers (adverts / job descriptions / contracts)                                                                     Yes / No

·        Dealing with problems (how to be assertive, supervising workers, disciplining staff, making complaints)      Yes / No

·        Other – what type?

How do you currently use your PB (or meet you care needs): Employ worker / use agency / buy equipment / do activities / holiday or respite / informal “thank-you” payments to friends or relatives/ other ……

If you have used / contacted the PB service in the last 6 months could you let us know what you think of the service and what difference it has made to you, if any.