PARADISE INDEPENDENT LIVING REFERRAL FORM Date : [date] SERVICE USERS’ DETAILS Name: D.O.B: Age: Current Address: Tel. N.O.: Religion: Ethnicity: NEXT OF KIN OR GUARDIAN DETAILS Name: Current Address: Tel. N.O.: Relationship: REFERRING AGENCY DETAILS Name of Referrer: Job Title: Agency Name & Address: Tel. N.O.: Mobile N.O.: Email: Fax. N.O.: Is Funding Approved: YesNo REFERRAL TIMESCALE We aim to see a prospective tenant within 5 working days. If the referral is urgent and needs to be seen within 2 working days, please tick this box What are the best days, time and place for us to meet with your client? OR Do you want to visit the supported housing scheme(s) first with your client: YesNo Do you want to visit the supported housing scheme(s) first without your client: YesNo PRESENTING ISSUES PRIMARY (TICK ONE ONLY) Mental health/personality disorderAspergers syndromeLearning disabilityPhysical disabilityBrain injuryAlcohol misuseDrug misuseCare leaverHomelessness SECONDARY (TICK ALL THAT APPLIES) Mental health/personality disorderAspergers syndromeLearning disabilityPhysical disabilityBrain injuryAlcohol misuseDrug misuseCare leaverHomelessness OTHER ISSUES : Please detail other presenting conditions that are identified OR submit up to date reports with details: Please indicate if report(s) are to be sent by: FaxEmailPostN/A CARE & SUPPORT REQUIRED (TICK ALL THAT APPLIES) Does he/she require assistance with any of the following areas? Please indicate level of assistance required H= High, M=Medium, L=Low, N= None Assistance required HMLN Budgeting HMLN Paying billsHMLN Accessing benefits HMLN Domestic life skills HMLN Personal hygiene HMLN Health & safety in the homeHMLN Escorting HMLN Accessing social & recreational activities HMLN Language and or literacy HMLN Access to education & employment HMLN Assistance required HMLN Behavior/anger management HMLN Medication/prescriptions HMLN Registering with primary care services HMLN Physical health care problems HMLN Nutrition/weight HMLN Family mediation HMLN Neighbours/peer mediation HMLN Vulnerable to exploitation HMLN Mobility HMLN Religious/cultural HMLN OTHER ASSISTANCE REQUIRED : Please detail other identified care and support needs OR submit up to date care or pathway plans with details. Please indicate if latter to be sent by: FaxEmailPostN/A RISK ASSESSMENT Arson HighMediumLowN/A Physical violence (to others) HighMediumLowN/A Verbal Aggression HighMediumLowN/A Damage to property HighMediumLowN/A Alcohol abuse HighMediumLowN/A Drugs/Substance abuse HighMediumLowN/A Sexual behaviour (risk to others) HighMediumLowN/A Self harm/Overdose HighMediumLowN/A Criminal behaviour HighMediumLowN/A Sleep disturbance/Nocturnal difficulties HighMediumLowN/A OTHER RISK ISSUES : Please detail other known risk to self or others OR submit up to date Risk Assessments with details Please indicate if latter to be sent by: FaxEmailPostN/A We operate a Lone Workers Policy for outreach support workers; if you are aware of any reasons why this may be unsafe, please state below: CONTACT DETAILS OF OTHER AGENCIES INVOLVED IN THE CLIENTS CARE OR SUPERVISION Name & Address of Agency Name of contact & telephone number ANY OTHER RELEVANT INFORMATION Click to download the PDF
