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

Paying bills

Accessing benefits

Domestic life skills

Personal hygiene

Health & safety in the home

Escorting

Accessing social & recreational activities

Language and or literacy

Access to education & employment

Assistance required HMLN

Behavior/anger management

Medication/prescriptions

Registering with primary care services

Physical health care problems

Nutrition/weight

Family mediation

Neighbours/peer mediation

Vulnerable to exploitation

Mobility

Religious/cultural

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

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