Walsall Learning Disability Floating support service referral form

  1. PERSONAL DETAILS (Customer Details)

Preferred Title: / Mr. / Miss / Mrs. / Ms / Other
Surname / Other Name Known as:
Name(s) / Date of Birth:
Address:
Post Code:
Home Tel. No: / Mobile Tel. No:
Work No: / National Insurance Number:
IF YOU DO NOT WISH TO BE CONTACTED AT THE ADDRESS ABOVE PLEASE PROVIDE US WITH AN ALTERNATIVE POSTAL ADDRESS:
Address:
Post Code:
Emergency Contact Information
Please tell us who you would like us to contact in the event of an emergency.
First Name
Address:
Post Code / Telephone No:
Referral Information
Details of person making referral if applicable
First Name
Address:
Post Code / Telephone No:
Date: / Time:
Ethnic Origin
We want to make sure that everyone who asks us for support is treated fairly and equally, whatever their race, colour or ethnic origin. To help us to do this, and for that reason only please answer the following
White: British / White: Irish / White: Other / Mixed: White & Black Caribbean
Mixed: White & Black African / Mixed: White & Asian / Mixed: Other / Asian/Asian British: Indian
Asian/Asian British: Pakistan / Asian/Asian British: Bangladeshi / Asian/Asian British: Other / Black/Black British: Caribbean
Black/Black British: African / Black/Black British: Other / Chinese/Other Ethnic Group: Chinese / Chinese/Other Ethnic Group: Other
Refuse to say / If you have listed Other: Please specify:
Faith/Religion
No religion/atheist / Muslim / Christian (all denominations) / Sikh
Buddhist / Hindu / Jewish / Prefer not to answer
Any Other: Please Specify
Sexual Orientation
We are asking all our customers if they would like us to record their sexual orientation. You do not have to answer this question, but if you are willing to share this information, it would help us to ensure that we do not discriminate against people on the basis of their sexual orientation.
Heterosexual / Bisexual / Lesbian / Homosexual
Transsexual / Prefer not to answer
Communication Needs
Do you need any of the following?
Large Print / Braille / Audiotape / Translation*
Interpreter* / Home Visits /  / Signer / Other*
If yes to any of the above please provide more details:
HEALTH AND WELLBEING Medication:
Please give details of any health issues that you may have:
Please list all prescribed medication you are currently taking and why you are taking it:
Medication / Dosage / Reason for taking it
GP Details:
Please give details of your GP
GP Name:
Address:
Post Code: / Telephone Number:
Criminal Record
Have you ever been convicted of a criminal offence or have any pending court appearances? If yes please give details: / Yes / No
Nature of offence / Date / Sentence Served

Please note that the declaration of criminal offence(s) does not necessarily mean that you will be excluded from being offered a support package

ADDITIONAL SUPPORT AND CONTACT
Please give details if you receive support or have regular contact with any other agencies:
Agency: / Name:
Address & telephone: / Relationship:
Agency: / Name:
Address &telephone: / Relationship:
PREVIOUS ACCOMMODATION/SUPPORT
Have you ever received accommodation and/or support fromHeantun Housing Association / Yes / No
If, yes please state date and address
  1. ABOUT YOUR NEEDS

Please tick what type of support you feel you will require from us to assist your independent living.

  1. ACHIEVE ECONOMIC WELLBEING
/ YES / NO
Manage/budget your money effectively
Get the right benefits
Reduce debt
Obtain paid work
Any other support needs
Comments:
  1. ENJOY AND ACHIEVE
/ YES / NO
Access training and/or education
Take part in hobbies/interests or practicing your faith
Access cultural sensitive services or activities
Access voluntary work or something similar
Meet new people or maintain contact with friends or family
Any other support needs
Comments:
  1. BE HEALTHY
/ YES / NO
Better manage physical health
Better manage mental health
Stop or reduce substance (drug/alcohol)
Obtain aids/adaptation for you or your home
Any other support needs
Comments:
  1. STAY SAFE
/ YES / NO
Find accommodation
Manage tenancy
Manage statutory orders (ASBO, probation order, court of protection)
Manage self harm
Avoid causing harm to others
Avoid others causing me harm
Any other support needs
Comments:
  1. MAKING A POSITIVE CONTRIBUTION
/ YES / NO
Get confidence
Have more choice
Get more involved in things
Comments:
I understand that Heantun Support Staff will carry out checks on the information provided through contact with other agencies, eg probation services, social services, health services etc.
As far as I know the information on this form is true and I will inform the provider of any changes
I understand that the supporting people providers have the right to refuse support if I have given any false information in this document
In order to assess your needs and help us to deliver an efficient service we need to collect relevant personal details. We comply with the Data Protection Act 1998 when dealing with personal data. This means that your personal data will be processed in accordance with the law. Please note we may share your personal data with other organisations where appropriate. By signing this form you are consenting to Heantun Housing association/Supporting People processing your personal data.
Full name of applicant: / Date
Signature:
Full name of Referring Agency/External Agency:
Signature: / Date

Please return completed and signed form to Staff at Walsall LD service, Heantun Housing association, 3 Wellington Road, Bilston, West Midlands, WV14 6AA or email to

Referral enquiries -

Referral form V1.09.2016