Referral Form

Service User Details
Date of Referral
Name
Date of Birth
Age
NI Number
Gender
Ethnicity
Primary Language
Any Dependents? (If so, please specify)
Current Address

Referrer Details
Name of Referrer
Job Title
Telephone Number
Mobile
Email
Address of Referrer

Next of Kin / Guardian Details
Name
Relationship
Telephone Number
Email
Current Address

GP Details
GP Name
Surgery
Telephone Number

Referral Type
General Referral (Within 5 working days)
Urgent Referral (Within 2 working days)
Emergency Referral (Within 24 hrs)

Does your Client have capacity to consent to this referral?
Yes
No	(please see below)

If No, please provide a copy of the following documents (tick appropriate)
Capacity Assessment
Best Interest Decision

Reason For Referral (MANDATORY) - Please complete in as much detail as possible.
Click here to enter text.
Does your client require Accommodation? - Please check as appropriate
Yes
No

Does your client require Accommodation? - Please check as appropriate
Yes
No

If yes, Which type of Supported Accommodation is required? - Please check as appropriate.
Shared/ Communal
Self Contained Flat

Location Preferences - Please tick as appropriate or specify your Client's preferred location to live
Birkenhead	Wallasey
Bebington	Liscard
Bromborough	New Brighton
Rock Ferry	Any
Prenton
Other	Click here to enter text.

Primary and Secondary Supporting Needs
PRIMARY (check only one)	SECONDARY (check all applicable)
Mental Health/Personality Disorder	Mental Health/Personality Disorder
Aspergers Syndrome	Aspergers Syndrome
Learning Disability	Learning Disability
Physical Disability	Physical Disability
Alcohol Misuse	Alcohol Misuse
Drug Misuse	Drug Misuse
Care Leaver	Care Leaver
Homelessness	Homelessness

Specific Care & Support Required - Please check as appropriate
Support Criteria	High	Medium	Low	None
Mental Health Monitoring
Emotional Support
Behaviour/Anger Management Support
Physical Health Care Support
Vulnerable to exploitation
Activities of daily living/domestic support
Personal Hygiene Support
Medication Administration/Prompt
Budgeting & Payment of Bills
Shopping
Nutrition/Weigh Support
Food preparation & Cooking
Leisure/Social Inclusion
Access to Education & Employment
Appointment Attendance Support
Health & Safety in the Home Support
Escorting / Accompanying
Benefit Entitlement Support
Religious / Cultural
Family Support / Mediation
Accessing Other Services

Do you have any other specific Care & Support Criteria that has not been listed? If so, please specify
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Risk Assessment - Please check as appropriate

Specific Risk	High	Medium	Low	None
Arson
Physical Violence (to others)
Verbal Aggression
Damage to Property
Alcohol Abuse
Drugs/Substance Abuse
Sexual Behaviour (Risk to others)
Self Harm/Overdose
Criminal Behaviour
Sleep disturbance/Nocturnal Difficulties
Other (please state)

Benefits currently awarded	Yes	No	Amount (if known
ESA
PIP (Daily Living Component) Standard
PIP (Daily Living Component) Enhanced
PIP (Mobility) Standard
PIP (Mobility) Enhanced
DLA (Care) Low
DLA (Care) Moderate
DLA (Care) High
DLA (Mobility) Low
Income Support
Other (Please State)

We operate a Lone Workers Policy for Community Support Workers; if you are aware of any reasons why this may be unsafe, please state below. If Service User has current or previous issues with drugs or alcohol, please elaborate (i.e. how much is consumed/how often).
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