Pathway CHC Support | CHC Eligibility Enquiry

Before you begin

This form gathers key information needed for initial NHS Continuing Healthcare (CHC) guidance. It is not an assessment and does not guarantee CHC funding.

A non-refundable processing fee of £50 is payable for each eligibility enquiry we review. After submitting the form, you will be taken to a secure Stripe payment page.

Section A: About You

If you are completing this form on behalf of someone else, you must provide a Health LPOA and send supporting documents to our secure email.

Your full name *

Your email address *

Telephone number (optional)

Your relationship to the person needing care *

Preferred contact method

Section B: About the Person Needing CHC

Approximate age (in years) *

Current setting

Local NHS area / ICB (if known)

Main diagnosis / conditions

Main reason care is required

Section C: Current CHC Position

Has an NHS CHC Checklist been completed?

Checklist date

Checklist outcome

Has a DST been completed?

DST date

DST outcome

Appeal timeframe

Any other deadlines?

Current funding (tick all that apply) Local authority social care
NHS-funded Nursing Care (FNC)
CHC already in place
Self-funding
Other

Further funding details

Section D: Overview of Needs by Domain

Please briefly describe the person’s needs in each area.

Behaviour – level of need

Description of needs

Cognition – level of need

Description of needs

Psychological & emotional needs – level of need

Description of needs

Communication – level of need

Description of needs

Mobility – level of need

Description of needs

Nutrition & hydration – level of need

Description of needs

Continence – level of need

Description of needs

Skin integrity – level of need

Description of needs

Breathing – level of need

Description of needs

Drug therapies / medication / symptom control – level of need

Description of needs

Altered states of consciousness (e.g. seizures) – level of need

Description of needs

Other significant needs – level of need

Description of needs

Section E: Risks, Night Needs & Carer Situation

Risks if the right care is not provided

Night-time needs

Impact on carers / family

Section F: Consent & Processing Fee

I confirm I have authority to share this information and that it is accurate to the best of my knowledge.

I understand the information provided will be used to offer general guidance on NHS Continuing Healthcare (CHC).

I understand that a processing fee of £50 is required and that payment is taken securely online via Stripe.