Client Contact Log
1st phone call ..................................
ENRYCH Personal Assistant Service
1st visit ............................................
Enquiry form and wish list
2nd visit ...........................................
Client details
Name: .........................................................................
3rd visit ...........................................
4th visit ............................................
Preferred title: Mr/Mrs/Miss/Ms/Other: ..................
Address: ......................................................................
Tel No (home): .......................................................
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Tel No (mobile): .....................................................
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Email: .....................................................................
Postcode: ....................................................................
Date of birth: .........................................................
Client prefers being contacted by  home phone
 mobile phone
 email
 other ................
Best time of day (eg after 10am, between 9 and 2pm etc): ...........................................................................
Days available: ................................................................................................................................................
Contact person in case of emergency
Name: .........................................................................
Relationship to Client: ...........................................
Address: ......................................................................
Tel No (home): .......................................................
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Tel No (work): ........................................................
Postcode: ....................................................................
Tel No (mobile): .....................................................
Information about Client
Please tell us about the Client’s disability. What is the disability called and how does it affect them?
(eg mobility, sight, hearing or communication issues) Please include any condition that is not immediately
obvious, but which may be relevant to a leisure activity eg epilepsy, agoraphobia, diabetes.
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Also, please tell us about the Client’s interests and skills. ..............................................................................
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533578196
What is your source of finance for PA support?
 Personal Budget (direct payment)  Personal Budget (managed payment)
 Self Funder
 Other .................................................
Is the Client interested in using the ENRYCH Provider Managed Account service?
 Yes
 No
How many hours of PA support per week are needed?
Please list the days and times required:
What’s important to me
Things I want my PA to support me to do
What difference will this make to me?
This role involves  Manual Handling  Food preparation  Use of car  .....................
Information relevant to risk assessment
Tasks required
Shopping
 Yes  No
Cleaning
 Yes  No
Preparing meals  Yes  No
Assist in/out of vehicles
 Yes  No
Assisting in leisure activities e.g. swimming
 Yes  No
Driving activities e.g. visit family/friends/hospital  Yes  No
Any other tasks, please specify: .....................................................................................................................
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For ENRYCH Use: Source of referral: .......................................... Referrer’s Name: ........................................................................
Job Title ............................................................. Phone ..................................................... Email .....................................................
533578196