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Personal Details
Basic Information of the person being referred
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Mental Health Needs
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Complex Care Needs
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Physical Health Care Needs
5
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Professional Support Network
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Convictions
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Applicant Statement
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Risk Assessment

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Service User Referral Form

Required Service

*Please tell us the service that you require:

Supported Living

Complex Care

Live-In Care

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Feel free to notify us if you are experiencing issues with this form, by sending us an email:

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Basic Details

*Service User’s Name:

*Phone Number

*National Insurance Number:

Current Address:

*Date of Birth:

*Date of Application:

*NHS Number:

*Gender:

*Nationality:

Next of Kin

Who is the applicants next of kin? Please give contact details:

*Name

*Address:

*Is the person currently receiving care in a care facility?

*Phone Number

Discharge & Commencement Dates

Expected Discharge/Release Date:

*Date Supported Living Required:

Reason for Referral

*Please tell us the persons current housing situation

*Reasons for seeking supported living:

*Reasons for seeking complex care support:

*Has the person ever lost their accommodation in the past?

Yes

I dont know

Please tell us why they lost they lost their accommodation

Activities of Daily Living

How does the person manage or cope in the following areas?

Paying Rent:

Cleaning:

Getting on with neighbours/housemates:

Keeping appointments:

Cooking:

Managing Finances & benefits:

Long Term Housing and Previous Addresses

Have any applications been made for long-term housing?(for example: council housing, housing associations, etc.)

Yes

I dont know

List of all addresses covering the last 5 years

Please give details of previous Addresses: (including name and contact details of each establishment)

*Year 1:

*Year 3:

*Year 5:

*Year 2:

*Year 4:

Additional Information (optional):

Mental Health

Needs, Diagnoses, Aftercare, and Medication

Mental illness/mental health needs:OPTIONAL: Only applies if the person has mental health needs

*Are they entitled to 117 after care?Please ask them

Yes

*Do they take prescription medication?

Yes

Please list inclusive details of mental health diagnosisOPTIONAL: Only applies if the person has formal mental health diagnoses

Prescribed Medication Details

*Medication:

*Dosage:

*Reason:

*Frequency:

*** To add more rows to enter additional records in list form, please use the plus (+) sign at the end of the above row.

Mental Capacity

*Does the person have Mental Capacity issues?

Yes

I dont know

*Severity level:

*Date of last episode:

*Triggers:

*Has a Mental Capacity Assessment been done?

Yes

I dont know

*Who conducted the assessment?

*Assessment date:

Additional informationIncluding triggers

Suicide Risk

Please Note: If a Care Coordinator or Social Worker is involved, they will have detailed information

*Does the person have Active Suicidal Ideation or a history of Suicidal presentation?

Yes

I dont know

*Severity level:

*Date of last episode:

*Triggers:

*Has the person made Attempts to end their life?

Yes

I dont know

*Severity level:

*Date of last episode:

*Triggers:

*Have they ever needed to be hospitalised as a result of self-harm?

Yes

I dont know

*Date of last hospital admission as a result of self harm:

*Are there any significant dates that can trigger relapse in this persons mental state?

Yes

*Date:

*Occassion / Triggers:

*Current Support Plan:

*** To add more rows to enter additional records in list form, please use the plus (+) sign at the end of the above row.

Self Harm

Please Note: If a Care Coordinator or Social Worker is involved, they will have detailed information

*Has the person ever deliberately harmed themself?

Yes

I dont know

*Severity level:

*Date of last episode:

*Triggers:

*How do they self-harm?What part of their body do they do they exercise self harm on, and what do they do (cut, burn, pinch, e.t.c)?

*What triggers them to self-harm?

*What methods and items do they use to self-harm?

Complex Needs

Complex Needs Specification

*Choose all complex needs options that apply to the applicant:You can choose more than one option

Criminal Behaviour

Substance Misuse (drugs, alcohol, e.t.c)

Violence and Aggression

Gambling

Other Complex Needs Behaviour(s)

Attention

When completing this section, please list all details comprehensively

Criminal Behaviour

Name of criminal act:

What do they do, and How?

Therapy or Medication:

*** To add more rows to enter additional records in list form, please use the plus (+) sign at the end of the above row.

Substance Misuse (including drugs and alcohol):

Substances taken:

How do they misuse the substances?

Therapy or Medication:

*** To add more rows to enter additional records in list form, please use the plus (+) sign at the end of the above row.

Violence and Aggression

Name of Aggression Action:

What do they do and How?

Therapy or Medication:

*** To add more rows to enter additional records in list form, please use the plus (+) sign at the end of the above row.

Gambling

Name of gambling Action:

What do they do and How?

Therapy or Medication:

*** To add more rows to enter additional records in list form, please use the plus (+) sign at the end of the above row.

Other Complex Needs Behaviour(s)

Name of OTHER complex action:

What do they do, and How?

Therapy or Medication:

*** To add more rows to enter additional records in list form, please use the plus (+) sign at the end of the above row.

Physical Illness/Condition, and Disability

Specify Needs

*Choose all physical condition options that apply to the applicant:You can choose more than one option

Physical Illness

Disability

Other Condition

Attention

When completing this section, please list all details comprehensively

Physical Illness

Name of physical illness:

Symptoms:

Therapy or Medication:

*** To add more rows to enter additional records in list form, please use the plus (+) sign at the end of the above row.

Disability

Including physical disability, learning disability, autism, and Aspergers Syndrome, e.t.c

Name of disability:

Symptoms:

Therapy or Medication:

*** To add more rows to enter additional records in list form, please use the plus (+) sign at the end of the above row.

Other Conditions

Name of "OTHER" condition or illness:

Symptoms:

Therapy or Medication:

*** To add more rows to enter additional records in list form, please use the plus (+) sign at the end of the above row.

Professional Support Network

Please give details of all multi-disciplinary team (MDT) agencies or supportive organisations that are involved in the persons care, including names and contact details.

MDT / Supportive Organisation

Name

WebsiteOptional

Address

*Name of Contact Person

Role

*Phone Number

*Email

*Comments / Additional Information

GP Details

Name of Practice

Company WebsiteOptional

Address

*Name of Contact Person

Role

*Phone Number

*Email

*Comments / Additional Information

Pharmacy

Prescription Collection Support

*Does the person require support with collecting prescriptions from the pharmacy?

Yes

I dont know

Name of Practice

WebsiteOptional

Address

*Name of Contact Person

Role

*Phone Number

*Email

*Comments / Additional Information

Criminal Offences Status

Has this person ever been convicted of a criminal offence?Providing false information will, in the future, invalidate any support contracts that may be entered into.

Yes

I dont know

IMPORTANT

Please list ALL convictions CLEARLY, with dates

Criminal Offences Details

Name of Offence

*Is the conviction still in force?

No - The sentence is served in full

Yes - I am still serving the sentence

N/A - The sentence was suspended

*Conviction Start Date

*Conviction End Date

Supervision Status

Has this person ever been under any form of supervision?Providing false information will, in the future, invalidate any support contracts that may be entered into.

Yes

I dont know

*Please tick all options that apply:You can choose more than one option

Custody Status

*Is the person currently in custody?

Yes

Please give details:

*Release Date:

Special NotesOptional

Panel Heading

Please Note:
This section helps us to hear the voice of the applicant, which helps us to plan and better understand their future support needs enough to inform meaningful planning of care in a tailored way.

Applicant statement about reasons for needing supported housing

*How will you make this statement?

I am able to make this declaration without someone elses support, and shall hereby do so

I DO NOT have mental capacity, or I have mental capacity to communicate my responses to this declaration, but I am unable to make the declaration due to disability. So, I am being supported by someone else

Supporting Person Confirmation

*In what capacity are you acting?

*Confirmation by a Professional (Best Interest)

I confirm that the applicant lacks capacity, according to the Mental Capacity Act, and I am authorised to support the applicant in making this declaration. I shall note down responses that are in the best interest of the applicant.

*Confirmation by non-professional supporting person (Family or Friend)

I confirm that I am authorised to support the applicant to make this declarion. I shall note down responses exactly as communicated by the applicant.

Best-Interest Professional

*NameSupporting person acting in a professional capacity for the best interest of the applicant

*Role

*Organisation NameThis may be an MDT agency or Charity

*Address of Organisation

WebsiteOptional

*Phone Number

*Email

Best-Interest Family or Friend

*NameSupporting person acting in a non-professional capacity for the best interest of the applicant

*Relationship

*Contact Address

*Phone Number

*Email

Applicant Self-Responses

The reason why I need supported housing is as follows:

Dream:Please tell us your dream for your future?

Belief:What do you believe you can achieve with this opportunity?

Aspirations:What do you aspire to do in your life, and what makes (or would make) your life meaningful?

Additional DetailsUse this space to add any aspects that may not be explicitely asked about in this section

Responses via a Supporting Person

The reason why the applicant needs supported housing is as follows:

Dream:Please tell us the dream for the applicants future?

Belief:What do you believe the applicant can achieve with this opportunity?

Aspirations:What do you believe the applicant aspires to do in their life, and what makes (or would make) their life meaningful?

Additional Details:Use this space to add any aspects that may not be explicitely asked about in this section

Statement from Referring agency

I have known/worked with the applicant for:

Years

Months

In what capacity have you known the applicant?

*Does the applicant have restrictions or orders in place?

Yes

*Select the restrictions that apply:You can select more than one option

Tag

Community Treatment Order (CTO)

S37/41 Ministry of Justice (MOJ)

Mental Health Act Sections (MHA)

Deprivation of Liberties and Safeguards (DoLS)

Care

Other

Please specify "Other"You can specify more separate "Other" in additional boxes

*Has the applicant ever recieved support from secondary mental health services?These include community-based and therapy-related mental health services

Yes

Please give information on past assessments/treatments episodes and history below:
(Add as many Hospital admissions as may apply)

*Reason for Contact:

*Name of Care Provider

Team Involved:

Admission Start Date:

Admission End Date:

*Risk Assessment Rating1 Star = Low Risk2 Stars = Medium Risk3 Stars = High Risk

LOW RISK

MEDIUM RISK

HIGH RISK

*Notes on Risk Assessment Rating:

Care Plan and Risk Assessement Documents

MANDATORY: You must send us copies of the applicants care plans and risk assessment documents as part of this referral process

*Please choose the format in which you wish to send the care plan and risk assessment documents

Digital (PDF, Docx, JPG, PNG, e.t.c)

Hard-Copy (in paper format - Hand delivered or via the post)

PLEASE NOTE

Processing of this application will not be finalised until copies of the applicants care plan(s) and risk assessment(s) are received by us via the post or hand-delivery.

*Care Plan Copies:You can upload multiple documents together

doc,docx,mpg,mpeg,mp3,mp4,odt,odp,ods,pdf,ppt,pptx,txt,xls,xlsx,jpg,jpeg,png,psd,tif,tiff

*Risk Assessment Copies:You can upload multiple documents together

doc,docx,mpg,mpeg,mp3,mp4,odt,odp,ods,pdf,ppt,pptx,txt,xls,xlsx,jpg,jpeg,png,psd,tif,tiff

Funding / Financial Support

*Does the applicant have access to funding or financial support?Such as: 117 Aftercare provision and similar others

Yes

Give details of the source of funding or financial support:

Since funding is unavailable for the applicant, give details of how we will be paid for providing services?