HSE

Home Support Service

for Older People

Information
Booklet
&
Application
Form

2023
 Home Support Service – Information Booklet

1. What is the Home Support Service?

The Home Support Service (previously known as Home Help Service or Home Care
Package Scheme) provides help and support with everyday tasks to older people living at
home. These tasks may include help with:

 getting in and out of bed

 dressing and undressing
 personal care such as showering and shaving

The HSE wishes to support you to remain in your own home for as long as possible. As part
of the Home Support Service, HSE staff will, based on your Care Needs Assessment and
having regard for your will and preference, consider what kind of support you might need.
These supports will then be provided by HSE staff or by external service providers who have
agreements with the HSE to provide this type of service on its behalf. If your Home Support
is being delivered by an external provider, you will be asked to choose from a list of Approved
Providers, which will be given to you by the HSE.

The HSE and its Approved Providers aim to minimise the number of Home Support staff
involved in providing your Home Support. However, there may be times when a number of
Home Support staff are involved, particularly due to leave arrangements and other service
demands. All providers, including the HSE, also endeavour to deliver the Home Support
Service at times preferred by you. It may not always be possible to facilitate all clients’
preferred times when developing the agreed Schedule of Services due to the number of
staff available at any one time and the care needs of their clients.

Consumer Directed Home Support (CDHS) is an approach to delivering Home Support in

your home. It offers you more choice in how the service is delivered. Please see appendix
on page 7 for more information. Should you wish to avail of Consumer Directed Home
Support, please indicate on the Application Form.

2. Who can apply for the Home Support Service?

The service is for people aged over 65 who need help to continue living at home. Sometimes
exceptions are made for those younger than 65 who may need support.

3. Where do I apply for the Home Support Service?

The HSE has 41 local Home Support Offices nationwide where you can send your
completed Application Form. The address for your local office is listed on the last page of
the Application Form.

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 Home Support Service – Information Booklet

4. How do I apply for the Home Support Service?

You must fill in an Application Form and send it to your local HSE Home Support Office.
Staff in your local office will be glad to assist you with filling in the Application Form or
answering any further questions you may have.

5. Who should fill in the Application Form?

To apply for Home Support services, you can complete the Application Form yourself or you
can ask your nominated support person to assist you to complete it for you. It is important
however, that you, as the person who needs the service, signs the Declaration and
Consent Section in Part 1 of the Application Form. This is because we need to confirm
that you want the support, that you have decided this for yourself and that your wishes are
being respected in this regard.

If you have difficulty accessing information or making an informed decision then you can be
supported by the Assisted Decision-Making (Capacity) Act 2015 (ADMA 2015) which
commenced on 26th April 2023. This Act recognises that insofar as possible, every adult will
be presumed to have capacity to make decisions for themselves, unless determined
otherwise.

The commencement of the Act establishes a tiered system of decision support

arrangements for people who may need help in making decisions, and provides for legally
recognised decision-makers to support a person to maximise their decision-making powers.

The Decision Support Service in an independent body and has published codes of practice
for decision supporters and relevant legal and healthcare professionals to provide guidance
for their functions and responsibilities under the ADMA 2015.

If you are unable to apply for Home Support services yourself, your decision supporter can
apply on your behalf. A decision supporter refers to a person who has been appointed as a
decision-making assistant, co-decision-maker, decision-making representative, power of
attorney or designated healthcare representative. The type of decision support provided
depends on the relevant arrangement in place and a decision supporter may be a family
member or trusted friend (decision-making assistant). Part 2 of this Application Form is
where your decision supporter (if any), explains why they are making this application on your
behalf. Further information available at the following link;

https://www.hse.ie/eng/about/who/national-office-human-rights-equality-policy/assisted-
decision-making-capacity-act/faqs/

6. What do I need to include with my Application Form?

No documents are required with your Application Form.

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 Home Support Service – Information Booklet

7. Sharing of my information
It is not possible to provide care without the collection and processing of personal data. The
personal details provided by you on the Application Form may be shared with HSE staff and
may include external Home Support providers and their staff who provide Home Support
services on behalf of the HSE. We use this data to coordinate the provision of home care
services to you.

To comply with Data Protection legislation, the HSE wishes to advise that information
supplied in the Application Form may be recorded electronically.

The Care Needs Assessment and other relevant Home Support documentation, including
personal data and details relating to your nominated support person / decision supporter
may be shared with relevant health professionals, which may include external approved
Home Support providers and their staff. Your information may also be shared with your
nominated support person / decision supporter (with your consent) in relation to the delivery
of your Home Support service.

Your personal records are secured in line with the HSE’s Information Security Policies,
which are aligned to industry best practice. All staff working for the HSE and those providing
services on behalf of the HSE, have a legal duty to keep information about you confidential
and staff are trained to ensure data is kept secure.

8. Can I apply for the Home Support Service while I am in a hospital or a

nursing home?
Yes. If you are in hospital, you (or your nominated support person / decision supporter)
should ask the person dealing with your Discharge Plan for a Home Support Application
Form. This person might be a nurse, a discharge coordinator or a social worker. They will
assist you in completing the Application Form and will send it to your local HSE Home
Support Office for processing. Submitting the Application Form as soon as possible during
your hospital stay may help avoid delays in your discharge home from hospital.

9. What happens after I submit the Application Form?

After the HSE receives your completed Application Form, the HSE will arrange to assess
what kind of support you might need. This is called a Care Needs Assessment (see Question
10).

10. What is a Care Needs Assessment?

During the Care Needs Assessment, a staff member such as a public health nurse,
physiotherapist or occupational therapist will find out what support you need. This
assessment is undertaken to make sure that you get the right support in the right place - this
might be in your home, in a hospital or in some cases, in a nursing home. During the
assessment, we will look at your care needs including:

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 Home Support Service – Information Booklet

 your ability to carry out the activities of daily living i.e. bathing, dressing,
shopping and moving around
 any medical, health and other support services being provided to you
 your family, social and community supports
 your wishes and preferences
 the areas of your life where you need support

Following your assessment, the HSE will then consider your application for a Home Support
Service. You will be informed in writing of the decision on what supports you need at that
time and if you are approved for the consumer directed approach (if you have chosen that
option) (see Appendix titled “Consumer Directed Home Support” at the end of this
information booklet and Application Form). The HSE Home Support Service aims to assist
and support people to remain at home and support informal carers. The service does not
replace informal care. It is not possible to deliver 24-hour care to individual clients in their
own homes, as funding available for the Home Support Service is limited.

If you are approved for a Home Support Service based on an assessment of your needs
undertaken while you are in hospital, the support provided will be on an interim basis to
enable you to return home. Your needs will be re-assessed within a short period of you
returning home and the level of Home Support may be adjusted to support your re-assessed
needs.

11. What can I do if I am not satisfied with the decision about my Home
Support Service Application?
If you are not satisfied with the HSE’s decision on your Home Support following your Care
Needs Assessment, you can write to the Home Support Office in your area within 20 days
of receiving the decision. Please include the reasons why you are not satisfied with the
decision. An impartial review of the decision will be undertaken and you will be informed of
the outcome of this review.

12. Will my income be assessed?

No. Your application for the Home Support Service is assessed on your care needs as
identified by health professionals.

13. Do I have to pay for the Home Support Service?

No. HSE funded Home Support is non-chargeable under existing government policy.
However, if you arrange other Home Supports, above the levels funded by the HSE, you will
have to pay for these extra supports.

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 Home Support Service – Information Booklet

14. What happens if my circumstances change while I am receiving the Home

Support Service?
If your circumstances change in any way that affects your need for Home Support, you or
your nominated support person/ decision supporter acting on your behalf, must notify the
local HSE Home Support Office by phone, email or letter. Examples of changed
circumstances include:

 improved independence as you recuperate after a time of being unwell

 admission to hospital
 availing of respite care in a hospital or nursing home
 temporary stay with your family or relatives in their home

From time to time, the HSE will review the Home Support Service you are receiving and,
depending on your care needs, may increase or decrease the supports you are receiving or
the supports may remain the same.

15. How can I make a comment or complaint about the Home Support
Service?
You have the right to complain if you are not satisfied about something we have done. If you
have a complaint, a comment or wish to complement our work, you can use the following
options:

 In Person: Talk to any member of HSE staff, service manager or complaints

officer
 Online Form: Send your complaint securely through the online feedback form
which is available on
www.hse.ie/eng/services/yourhealthservice/feedback/complaint
 By Email: Email [email protected] with your feedback
 By Letter: Send a letter or fax to your local Home Support Office. Staff can help
you put your complaint in writing, if you require assistance
 By Feedback form: Complete a Feedback form, available at most HSE
reception areas, and leave it in the identified areas provided by the local service
you are using or visiting. You may also give it to a member of staff or ask a staff
member for an address. The form is also available online in 9 languages on
www.hse.ie/eng/services/yourhealthservice/feedback/complaint
 Ring us: LoCall 1890 424 555: Your call will be answered by a staff member
from the National Complaints Governance and Learning Team

If some, or all, of your Home Support services are being provided by an external service
provider and you are not satisfied with the service, please contact the service provider first.
If you wish, you may then make your complaint to the HSE using any one of the options
outlined above.
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 Appendix – Consumer Directed Home Support (CDHS) Information Sheet

APPENDIX – Consumer Directed Home Support (CDHS)

1. What is Consumer Directed Home Support (CDHS)?

If you are approved for a Home Support Service and HSE staff are not available to deliver
the service, then an external provider, who has been approved by the HSE, will deliver
the Home Support to you. The HSE can arrange this service with an Approved Provider
on your behalf. Alternatively, you can apply to be considered for CDHS. The CDHS
approach will facilitate you to deal directly with the HSE Approved Provider(s) of your
choice and to arrange days and times of service delivery. If you apply for, and are
approved for this approach, the HSE will give you a letter approving a weekly amount of
funding which you can use to arrange Home Support from your choice of provider(s)
approved by the HSE.

The number of hours of Home Support delivered by your chosen provider depends on
the rates charged by the provider and the days and times you choose to have your care
delivered. Your provider will advise you of their rates when you are agreeing your Care
Plan with them. Providers are not permitted to charge rates for services, or any other
fees or charges, that are higher than (or in addition to) what they have agreed with the
HSE.

2. How do I apply for Consumer Directed Home Support?

See Question 2 to Question 10 as this information applies to all applications for Home
Support. The standard Application Form must be completed and returned to the local
HSE Home Support Office. If you would like to be considered for CDHS, you need to
indicate your wish on the Application Form. A Care Needs Assessment will be completed
(see Question 10).

You will be informed in writing of any supports being approved based on your Care Needs
Assessment and if you are approved for the Consumer Directed approach.

3. What are my (and my family carer and/or nominated support

person/decision supporter) responsibilities if I am approved for
Consumer Directed Home Support?

Your responsibilities, if you are approved for Consumer Directed Home Support, are:

 To utilise the funding approved by the HSE for Home Support for personal
care and essential household duties, respite care, companionship or other
specific services which are essential to you remaining at home and
maximising your ability to live as independently as possible

 To prioritise specific requirements, identified by the HSE Care Needs

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 Appendix – Consumer Directed Home Support (CDHS) Information Sheet

Assessment, in the arrangements with your chosen service provider so that

the HSE and you are satisfied you are receiving these important personal
or time specific requirements

 To use only Home Support providers approved by the HSE - payment will
not be made to providers who are not HSE approved (the HSE will provide
you with a list of Approved Providers)

 To make arrangements directly with your chosen provider to agree a

schedule of services, Care Plan and days and times of service delivery.
Before you decide which provider to use, you may wish to discuss your
requirements (days and times of service delivery) with a number of
providers so that you can compare the services that they are able to provide

 To agree with your provider how any changes to the agreed arrangements
are to be managed e.g. how much notice does the provider need if you want
to rearrange days and times of service delivery

 To assure yourself, prior to signing any schedule of services, that you are
satisfied with the service being offered by your chosen provider. If you
subsequently become dissatisfied with the service being delivered, you
should discuss your concerns with your provider. In the event that you are not
satisfied with their response, you can submit a complaint to the HSE (see Question
21)

 To sign the schedule of services/Home Support Care Plan to confirm

agreement with the provider

 To certify that the Home Support service has been provided as agreed or to
identify any gaps in service delivery to enable the HSE to pay the provider’s
invoice correctly. The HSE will check that the invoiced rates are not in
excess of the rates agreed with the individual provider

 To advise the HSE of any delays in the commencement of your Home

Support once approved

 To advise the HSE local Home Support Office if any concerns arise in
relation to delivery or quality of Home Support

 To advise the HSE immediately if the full value of services approved are not
being utilised/not needed/not provided each week. Any hours unused by
you cannot be banked or held over for use at another time. The HSE does
not pay the provider for hours that are not delivered to you

 If you stop the service for any reason, you must advise the HSE so the HSE
can assist you in re-arranging services if you need such assistance

 To advise the HSE local Home Support Office immediately if your

circumstances change such as admission to residential or acute care or

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 Appendix – Consumer Directed Home Support (CDHS) Information Sheet

where the Home Support service is ceased/suspended

 To notify the HSE immediately if your Home Support service is no longer

required

4. What are my Home Support Provider’s responsibilities if I

am approved for Consumer Directed Home Support?
Your Provider has the following responsibilities when Home Support is
approved under a Consumer Directed approach:

 To advise the HSE immediately of the following:

 If there appears to be a lack of full understanding of the choices you make

with regard to services to be provided and/or days and times of service
delivery

 If care is refused or episodes of care are regularly curtailed

 If there is a change in your circumstances such as admission to residential

or acute care or where the Home Support service is ceased/suspended or
care is stopped unexpectedly

 If a serious complaint is made regarding the Consumer Directed approach

and it cannot be resolved between you and your provide

 If there is an unreasonable delay to the commencement of the Home

Support service once the service has been approved

 If the full value of services approved are not being utilised or not needed
each week or if the service is no longer required

 To provide you and your family carer with documentation explaining how
the monetary value of the HSE’s approval for a service is converted to
hours of service. This is having regard to the rates agreed with the HSE or
such lower rates as the provider may determine with you. The provider is
responsible for ensuring that the rates charged do not exceed HSE agreed
rates, and the provider must not charge fees or other charges for HSE
funded services

 To invoice the HSE only for the actual service delivered to, and certified
by you, and within the monetary value approved by the HSE

 To provide you with services that fall within the scope of the tendered
services i.e. personal care and essential household duties relating to you,
respite care, companionship or other specific services that are essential to
maintaining you at home and maximising your ability to live as
independently as possible. The delivery of the service should support you

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 Appendix – Consumer Directed Home Support (CDHS) Information Sheet

to undertake tasks where possible rather than to do the tasks on your

behalf

 To prioritise specific requirements, identified by the HSE assessment, in

the arrangements with you and your family carer

 To agree days and times of service delivery with you and your family carer

 To agree with you and your family carer how changes to the agreed
arrangements are to be managed (any such changes must comply with
HSE Service Arrangements)

 To sign a schedule of services/Home Support Care Plan to confirm

agreement and provide a copy to the HSE clearly showing your name,
address and date of birth, date agreement was made with you, hours of
service you will receive and cost of the service within HSE approved
monetary value per week

 To certify that the Home Support service has been provided as agreed
and/or to identify any gaps in service delivery in order to enable the HSE
to pay the provider invoice correctly

 To be aware that you may opt out of the Consumer Directed approach or
may become unsuitable for Consumer Directed approach over time as
your circumstances change

 To not engage in direct marketing of their services (including soliciting,

junk mail, cold calling or door stepping) to those in receipt of a Home
Support service. This is to ensure the protection of vulnerable adults

 To ensure that the implementation of the consumer directed approach

does not lead to adverse medical, physical or social risks for you

 To identify to the HSE if any concerns arise in relation to the delivery of

HSE funded Home Support

5. What are the responsibilities of the HSE if I wish to avail of/am

approved for Consumer Directed Home Support?
The HSE has the following responsibilities in arranging Consumer Directed Home
Support:

 To consider the Consumer Directed approach to Home Support service

delivery as part of your overall assessment where HSE direct services are
not available and where you indicate a wish to avail of this option

 To provide information on the Consumer Directed approach to you and/or

your family carer

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 Appendix – Consumer Directed Home Support (CDHS) Information Sheet

 To make contact promptly with you in any of the following circumstances:

 If there appears to be a lack of full understanding of the choices

you make and responsibilities being assumed

 If Home Support is not arranged by you with your chosen provider

within a reasonable time following HSE approval (you are to advise
the HSE of any delays). The HSE will contact you if they have not
received the Home Support documentation showing the schedule
of services agreed between you and your chosen provider. This
documentation is to be submitted by your provider within 2 weeks
of HSE approval

 If you refuse care or regularly curtail episodes of care, the HSE will
need to understand why and to consider if other arrangements are
more suitable for delivering your Home Support or if alternative
care arrangements need to be considered

 To implement HSE complaints procedures if a serious complaint is made

regarding consumer directed approach and it cannot be resolved between
you and your provider

 To pay the provider for the services delivered as invoiced by the provider
and certified by you, and within the terms of the HSE’s arrangements with
the provider

 To implement the processes set out in relation to the Consumer Directed

approach to Home Support delivery

6. Can I choose to move from CDHS and avail of the traditional model
of Home Support if I wish or if my circumstances change?
Yes. You will be facilitated to move from CDHS and avail of the traditional model of
Home Support if you wish or if your circumstances change. Please advise the HSE
and your Home Support Provider of this. A period of notice will be required to ensure
continuity of care.

If you decide not to apply for Consumer Directed Home Support in your application,
you can ask the HSE at any time to consider you for this approach to the delivery of
your service

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 Form HSS01 – Home Support Application Form

Home Support Service

Application Form Form HSS 01
You can use this Application Form to apply for the Home Support Service. Home Support provided by the HSE aims to
help an older person to be cared for in their own home. Completed Application Forms should be returned to your
local HSE Home Support Office. Staff in that office can also help you to complete your application. Contact details for
HSE Home Support Offices are provided on the last page of this form. Before completing this Application Form, you
can read more detailed information on the service in the Home Support Service Information Booklet.

Part 1 - Your Details - Please use BLOCK Capitals

NAME OF APPLICANT:
Home Address:

Eircode:
Date of Birth: D D M M Y Y Y Y Gender: Male Female
Daytime Mobile or
phone alternative
number phone number
GP NAME: PUBLIC HEALTH NURSE NAME:
Address: Address:
Telephone Number: Telephone Number (If known):
IF LIVING WITH RELATIVES/IN A HOSPITAL/NURSING HOME, STATE CURRENT ADDRESS:

IF IN A HOSPITAL/NURSING HOME, PLEASE ALSO COMPLETE THE FOLLOWING:

1. Name of Ward/Unit:
2. Date of admission:
3. Expected date of discharge:
4. Medical Record Number:
FAMILY/INFORMAL SUPPORT CONTACT DETAIL (someone nominated by you to assist):* Not Mandatory to complete

FAMILY MEMBER CONTACT NAME: Relationship to Applicant:

Address:
Eircode:
Telephone Number:
Name and contact number of the person who will help you make arrangements for your Home Support:

Relationship to Applicant:
Do you want your personal details shared (Care Needs Assessment/Home Support Care Plan) shared with your
nominated contact person about your Home Support service? Yes ☐ No ☐

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 Form HSS01 – Home Support Application Form

Department of Social Protection Supports

Is Carers Allowance/Carers Benefit/Respite Care grant currently being paid to someone to care for you?

Yes No

If Yes, please state what type of payment(s)?

Does the person live with you at your current address? Yes No

If no allowance is being paid, it may be that your family carer should apply for one of these supports. More information is available from
your local Department of Social Protection, Social Welfare Office. Contact details are available on www.welfare.ie

Declaration and Consent

I wish to apply for the Home Support Service. I understand that this application is for support in my home and if my
assessed needs can be met from other community services e.g. Day Care, Meals on Wheels etc. then I may not
receive Home Support at this time.

Signed: Date:

1. Personal details may be shared by HSE staff and may include external Home Support providers and their staff
who provide services on behalf of the HSE. We use this data to coordinate the provision of home care services
to you.

2. Personal details provided by a family member/informal nominated support person/ decision supporter in
completion of the Application Form may be shared with HSE staff and may include external Home Support
providers and their staff who provide services on behalf of the HSE. We use this data to assist in coordinating
the provision of home care services to you.

3. External Home Support providers are bound by the HSE via confidentiality agreements and service level
arrangements, and are obliged to keep personal data secure, and to use it only for the purposes specified by the
HSE.

4. The HSE’s legal basis for processing of personal data is as follows:

The processing is necessary for a task carried out in the public interest or in the exercise of official authority
vested in the controller; for the HSE this official authority is vested in us through the Health Act 2004 (as
amended). The processing is necessary in order to protect the vital interests of the person. This would apply in
situations where we share your personal data with health care personnel of the HSE and external Home Support
providers and their staff that provide a service on behalf of the HSE.
5. This information is kept by the HSE for as long as necessary. Records are maintained in the line with
recommendations of the HSE retention policy, which can be found at https://www.hse.ie/eng/gdpr/data-
protection-covid-19/record-retention-policy-2013.pdf
The HSE Privacy Notice for Patients and Service Users is available from your local Home Support Office or on
https://www.hse.ie/eng/gdpr/hse-data-protection-policy/hse-privacynotice-service-users.pdf

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 Form HSS01 – Home Support Application Form

6. I am aware that I must report to the HSE, immediately, any changes in my circumstances which may affect my
Home Support Service, i.e. admission to hospital, availing of respite care, a period away from home to stay with
family members or if I am able to manage at home without supports.

7. I have read and understand the information relating to Consumer Directed Home Support (CDHS). If HSE staff
are not available to deliver my Home Support, and if I meet the criteria for CDHS, I wish to avail of this approach
to the delivery of my Home Support.

Yes No

8. The content of the Care Needs Assessment report and other relevant Home Support documentation including
personal details or details of nominated support person /decision supporter provided in this Application Form
may be provided to, or shared with, relevant health professionals and external Home Support providers and
their staff, if required.

9. As part of this application, I confirm that I have read Page 4 & 5 of the Information Booklet which explains what
is involved in a Care Needs Assessment, and I give consent for the HSE to make arrangements for a Care Needs
Assessment to be undertaken.

10. I confirm that I have read and understand this Application Form. I have read the statement above and I confirm
that the information given by me on this Application Form is correct to the best of my knowledge and belief.

Signed: Date:

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 Form HSS01 – Home Support Application Form

Part 2 – To be completed only where the person who may need

Home Support is unable to make this application him/herself

I, hereby wish to apply for / refer

for Home Support as it appears he / she may need Home Support
in order to remain at home; he / she wishes to remain at home and is unable to make the application on his / her own behalf
due to

I can confirm that I am a nominated decision supporter as outlined hereunder;

- Nominated Support Person (informal arrangement) ☐

- Decision-Making Assistant ☐

- Co-Decision-Maker (form to be signed by both parties) ☐

- Decision-Making Representative* ☐

- Enduring Power of Attorney* ☐

- Designated Healthcare Representative* ☐

* These arrangements are formal arrangements, made via the courts and registered with the Decision Support Service.

I have discussed the application with him/her and I have informed them that this application is being made on their behalf.

1. Personal information provided below may be shared with HSE staff, and may include external Home Support providers and
their staff who provide services on behalf of the HSE. This information may be used in conjunction with the Home Support
Application for the applicant.

2. External Home Support providers and their staff are bound by the HSE via confidentiality agreements and are obliged to
keep personal data secure, and to use it only for the purposes specified by the HSE.

3. The HSE’s legal basis for processing of personal data is as follows:

The processing is necessary for a task carried out in the public interest or in the exercise of official authority vested in the
controller; for the HSE this official authority is vested in us through the Health Act 2004 (as amended).

The processing is necessary in order to protect the vital interests of the person. This would apply in situations where we
share your personal data with health care personnel of the HSE and Home Support providers and their staff that provide a
service on behalf of the HSE to the applicant.

4. This information is kept by the HSE for as long as necessary. Records are maintained in the line with recommendations of
the HSE retention policy, which can be found at https://www.hse.ie/eng/gdpr/data-protection-covid-19/record-retention-
policy-2013.pdf

5. The HSE Privacy Notice for Patients and Service Users is available from the local HSE Home Support Office or on
https://www.hse.ie/eng/gdpr/hse-data-protection-policy/hse-privacynotice-service-users.pdf

Signed: Date:

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 Form HSS01 – Home Support Application Form

Name of person applying on behalf of client (in BLOCK Capitals)

Address:

Eircode:

Date D D M M Y Y Y Y Phone Number

If this application is being made by anyone other than the client or his/her representative, please tick the appropriate box
below:

A note for Healthcare Professionals:

In circumstances where the healthcare professional has:
a) Established a lack of capacity (including a lack of capacity to consent to the sharing of information and/or to a Care
Needs Assessment) and has
b) Established the application is the “will and preference” ” of the applicant, please keep a record in your clinical notes of
how you reached your conclusion.

SOURCE OF REFERRAL (PLEASE TICK – identifying where applicant is resident on date of application)

Community Acute Hospital Other (specify)

Name of Location

Date

Completed Application Forms should be sent to the local HSE Home Support Office. Staff in that office can also assist you
in completing the application.

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 Home Support Offices – Local Health Offices

Local Health Office Home Support Office Address Local Health Office Home Support Office
Cavan Home Support Service, Services for Older People, HSE, Community Care, Leitrim Home Support Service, Services for Older People, HSE, Leitrim
Lisdarn Community Services Building, Cavan Hospital Complex, Co. Road, Carrick-on-Shannon, Co. Leitrim
Cavan Tel: 071-9650340 / 071-9650315
Tel : 049-4373131 / 049-4373141 /049-4373142 /
049-4373197
Carlow / Carlow: Home Support Service, Services for Older People, HSE, Laois Home Support Service, Services for Older People, HSE, C/O St
Kilkenny Community Services, St. Dympna’s Hospital, Athy Road, Carlow. 059 Vincent’s Community Nursing Unit,
9178016/ 059 9178065. Mountmellick, Co. Laois
Kilkenny: Home Support Service, Services for Older People, HSE, Tel: 057-9359575 / 0579359576 / 057-9359578
Community Services, James' Green, Kilkenny Tel: 056-7784647/ 056
7784745
Clare Home Support Service, Services for Older People, HSE, St. Joseph's Limerick Limerick City: Home Support Office, 2nd Floor, Roselawn
Hospital, Lifford Road, Ennis, House, National Technology Park, Castletroy, Limerick.
Co. Clare V94 6K65. Tel: 061 492 132 / 061 492 131 / 061 492 129
Tel: 065-6863858 / 065-6863859 / 065-6863812 Kilmallock: Home Support Office, Primary Care Centre,
Kilmallock Business Park, Co. Limerick. V35 K389.
Tel: 063 369 28
Newcastle West: Home Support Office, Newcastle West Health
Centre, Gortboy, Newcastle West, Co.Limerick. V42AN23.
Tel: 069 665 96
Cork - North Home Support Service, Services for Older People, HSE, Room 52, Floor 1, Longford Home Support Service, Services for Older People, Unit 20,
Cork / North Lee Block 8, St. Finbarr's Hospital, Douglas Road, Cork Daingean Hall, N4 Axis Centre, Battery Road, Co. Longford
Tel: 021-4923959 Tel: 043-3339780 / 043-3339781

Cork - South Home Support Service, Services for Older People, HSE, Room 52, Floor 1, Louth Home Support Service, Services for Older People, HSE, Oriel
Lee / West Cork Block 8, St. Finbarr's Hospital, Douglas Road, Cork Suite, St Brigid's Campus, Kell’s Road, Ardee, Co. Louth
Tel: 021-4923864 Tel: 041-6859200
Donegal 1st Floor, St. Conal’s Hospital, Letterkenny, Mayo Home Support Service, Services for Older People, HSE, St.
Co. Donegal Mary's H.Q., Castlebar, Co. Mayo
Tel: 074 9104775 Tel: 094-9049177
Dublin North Home Support Service, Services for Older People, HSE, Fujitsu House, Meath Home Support Service, Services for Older People, HSE, Floor 1,
Unit 100, 1st Floor, Beechmount Shopping Centre,
Lakeshore Drive, Airside Business Park, Swords, Co. Dublin Tel: 01- Trim Road, Navan, Co. Meath
8953760 Tel: 046-9037778 / 046-9037781 / 046-9037782
Dublin Home Support Service, Services for Older People, HSE, Ground Floor, Monaghan Home Support Service, Services for Older People, HSE, Primary
North Central Unit 4 & 5, Nexus Building, Care Services, Rooskey,
Block 6A, Blanchardstown Corporate Park, Dublin 15 Co. Monaghan
Tel: 01-7785602 / 01-7785607 / 01-7785606 Tel: 046-9037778 / 046-9037781 / 046-9037782
Dublin Home Support Service, Services for Older People, HSE, Ground Floor, Offaly Home Support Service, Services for Older People, HSE, Beside
North West Unit 4 & 5, Nexus Building, Riada House, Arden Road,
Block 6A, Blanchardstown Corporate Park, Dublin 15 Tullamore, Co. Offaly
Tel: 01-8975170/ 01-8975184 / 01-8975122 / 01-8975151 Tel: 057-9359700 / 057-9359701 / 057-9359702
Birr Office Tel: 057-9125857
Dublin Home Support Service, Services for Older People, HSE, Junction House, Roscommon Home Support Service, Services for Older People, HSE,
South City Kilnamanagh-Tymon Primary Care Centre, Airton Road, Tallaght, Dublin Government Buildings, Convent Road,
24 Co. Roscommon
Tel: 01-9214718 Tel: 090-6637520 / 090-6637522
Dublin Home Support Service, Services for Older People, HSE, Vergemount Hall, SIigo Home Support Service, Services for Older People, HSE,
South East Clonskeagh, Dublin 6 Markievicz House, Barrack Street, Co Sligo
Tel: 01-2680570 Tel: 071-9321080 / 071-9321082 / 071-9321018 /
071-9321079
Dublin Home Support Service, Services for Older People, HSE, Junction House, North Nenagh: Home Support Service, Services for Older People,
South West Kilnamanagh-Tymon Primary Care Centre, Airton Road, Tallaght, Dublin Tipperary HSE, Health Centre, Tyone, Nenagh, Co. Tipperary
24 Tel: 067-46440 / 067-46452 / 067-46462
Tel: 01-9214718 Thurles: Thurles Primary Care Centre, 22A Mitchel Street,
Thurles, Co Tipperary. Eircode: E41 K4C2.
Tel: 0504 258 86 / 0504 258 85
Dublin West Home Support Service, Services for Older People, HSE, Junction House, South Home Support Service, Services for Older People, HSE, Clonmel
Kilnamanagh-Tymon Primary Care Centre, Airton Road, Tallaght, Dublin Tipperary- Community Care Centre, Western Road, Clonmel, Co. Tipperary
24 Tel: 052-6177258 Cahir/Cashel: 062 27961 Tipperary
town/Dundrum: 062 27931 Carrick on Suir/Slieve Ardagh: 062
Tel: 01-9214718 27932
Dun Laoghaire Home Support Service, Services for Older People, HSE, Dun Laoghaire Waterford Home Support Service, Services for Older People, Waterford
Local Health Office, Residential Care Centre, Johns Hill, Waterford. Tel: 051-848936 ,
Tivoli Road, Dun Laoghaire, Co. Dublin Tel: 051-847279 , Tel : 051 848940
Tel: 01-2365200
Galway Home Support Service, Services for Older People, HSE, Lá Nua, Westmeath Home Support Service, Services for Older People, HSE, Health
Castlepark Road, Ballybane, Centre, Old Longford Road, Mullingar, Co. Westmeath
Co. Galway Tel: 044-9395082 / 044-9395021 \ 044-9395006
Tel: 091-748474 / 091-546062 / 091-546353
Kerry Home Support Service, Services for Older People, HSE, Rathass Health Wexford Home Support Service, Services for Older People, HSE,
Centre, Rathass, Tralee, Community Services, Slaney House, Newtown Road, Wexford
Co. Kerry Tel: 053 9160262 Tel: 053 9160265
Tel: 066-7184555 Home Support Services, Healthy Living Centre New Ross :
Tel 053 440 285

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 Home Support Offices – Local Health Offices
Kildare / West Home Support Service, Services for Older People, HSE, Junction House, Wicklow Home Support Service, Services for Older People, HSE, Block B,
Wicklow Kilnamanagh-Tymon Primary Care Centre, Airton Road, Tallaght, Dublin Civic Centre, Bray,
24 Co. Wicklow
Tel: 01-9214718 Tel: 01-2744200

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