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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