Section 17 Funding Application
Please complete Fully ALL AREAS of this form. The information provided will support your application for funding and will delay the Funding Agreement if not completed.
Client Details / Clients Full Name & Title / NHS Number
Date of Birth / Address including Post Code
Ethnicity / Mental Health Status or Section (Please advise if Section 17 Leave)
Practitioners Details / Name/Address of GP / Your PCT/Organisation
Care Coordinator Name, Contact Number and E-mail / Referring Consultant, Contact Number & E-mail
Client's Current Situation / Summary of current situation. Include Location, Assessed Needs and how these are being met and other relevant information on condition in support of your application. Please Be concise in your response.
Preferred Provider Details / Provider Organisation Name(s) / Organisation Address(es)
Contact Name / Contact Telephone, E-mail & Fax
Anticipated Unit Cost. / Specify if Cost is for Day, Week, Month, Year
Expected Start Date / Expected End Date/Repatriation
Is Provider Service CQC Registered?
Describe any current compliance actions.
Details of Service Offered by Preferred Provider / Please state why this is the appropriate provider. Exact requirements of placement, included expected outcomes,) how long the placement is expected to last, how the IPP Office will be informed of progress.
How does this care package meet the appropriate NICE guidance?
Justification for Funding Application / Describe all Local Options and processes considered for meeting this need and risk assessments undertaken prior to consideration of external placement. Include description of continued locality engagement and return care pathway options following placement.
CFT Shipps Process / Date Case Presented to Shipps Panel / Outcome of Shipps Panel and named contact for further information
Section 17 leave: Funding Support at end of leave / Please describe the actions taken/being taken to ensure that the appropriate funding is in place after the end of Section 17 Leave
Substance Misuse Tier 4 Panel only / Date Case Reviewed by Tier 4 & Outcome? / Period of Funding Agreement
Supporting Information / Please Indicate which Documents have been included in Support of your Application. E.G.CPA Report, Care Plan, Health Assessment
Your Details / Your Name and Designation / Address, Telephone and E-mail
Date of Application / Proposed Review Date and Who will Undertake review
Please email your completed application and attachments to: