Referral/Application for Services

Referral/Application for Services

To reduce delays in processing your application, please complete all sections where possible.
Please PRINT all information clearly.

Personal Information

Name of person requiring services:
Sex: M F / Date of Birth: / / /
Address: / Current Address: / Address at time of injury (if not current):
Mobile Phone : / Home Telephone:
Email address:
Nationality: / English Spoken? / Y N / Language: (if N)
Name of GP: / GP Telephone:
Address of GP:

Nominated Family Member/Carer

Please give the name of a family member or carer who may be contacted by Headway

Is this person the emergency contact person also? o Yes o No

Name: / Relationship to client:
Address: / Telephone:
Email:

Emergency Contact

If the nominated family member is not the emergency contact person, please identify on the lines below the name and telephone number of an emergency contact for the person applying for services:

Name of an emergency contact person for applicant:______

Applicant’s relationship to that person (e.g. partner, wife, husband, friend etc.) ______

Emergency contact mobile / landline number: ______

Source of Referral

Name of person completing this form/referral agent:
Please provide name of agency if professional:
Contact Telephone: / Relationship to client:
Contact email:
Contact address:
How did you hear about Headway?:

Details of Acquired Brain Injury (ABI)

Cause of Injury:
Please specify, e.g. Road Traffic Accident, Fall, Stroke, Haemorrhage, Assault etc.
Date of Injury:
Please provide the names, addresses and telephone numbers of the following if applicable
(please continue on a separate sheet if you need):
Name of Hospitals/Centres Attended since Injury
e.g., NRH, Enable Ireland, Beaumont Hospital, Physiotherapy, Occupational therapy etc. / Date from/to / Name of Consultant/ Professional

Current Needs and Difficulties

Does the client have any difficulty in the following areas as a result of the braininjury?
Physical: Please specify which of the following applies (e.g. Vision, Hearing, Weakness, Reduced Mobility, Fatigue/Tiredness, Epilepsy, sexual functioning etc.)
Cognitive: Please specify which of the following applies (e.g., Attention, Memory, Planning, Orientation, Communication, Speech, Intimacy, Lack of Motivation, etc.)
Behaviour: Please specify which of the following applies (e.g., Irritability, Aggression, Inappropriate/Antisocial, Impulsivity, etc.)
Emotion: Please specify which of the following applies (e.g., Mood Swings, Depression, Anxiety, Reduced Confidence, Anger etc.)
Reduced Awareness/Insight: Please give details
Current Social Situation: Please specify your current living and employment situation:
Live Alone / Y N / Live in permanent Accommodation / Y N
Live with Parents / Y N / Live in temporary Accommodation / Y N
Live with Spouse/Partner / Y N / Other (please specify) / Y N
Currently Employed / Y N
Currently Engaged in Training / Y N
Other activities you are involved in:
Functional/Personal Needs: Please specify (e.g., eating, drinking, toileting, transfers unaided)
Please list all current medication:
Please list the services the client is currently attending or applied to:
Reason for referral/expectations:
PLEASE ENSURE YOU CLEARLY STATE THE REASON FOR APPLYING TO HEADWAY.
Any other information you wish to include:

Permission to Contact – Fundraising/Research

From time to time Headway may wish to contact you to inform you or your nominated family member of events and fundraising opportunities. Headway will not share this information with any other body or institution. Are you willing to be contacted in this way? Yes □ No □

If yes, please contact me using the following methods only:
(Please tick all that apply)
By Post / □ / By email / □ / By Phone Call / □ / By Text Message / □

We occasionally seek permission from people to participate in research to help improve our services. Are you willing to be contacted in this way? Yes □ No □

Please turn over

Protecting Your Personal Information – the Limits of Confidentiality

Your private personal information will always be treated with respect. There are some rare occasions on which it may be necessary to share information about you without your permission. These occasions include:

·  If it is necessary to prevent harm to you

·  If it is necessary to prevent imminent harm to someone else

·  If you tell us about a situation in which a person under the age of 18 is or may be in danger of harm

·  If we are required to do so by law, for example if ordered by Court, or required by Gardaí

·  If necessary in the interest of public safety

The full version of the Headway policy on Data Protection lists all the possible reasons we might give your information to another person without your permission. This is available on request from any member of staff or from the Headway website at www.headway.ie/privacy

Consent to be Signed by Applicant

1.  I give consent for information on my medical, educational and occupational history to be released to Headway Ireland.
2.  I give consent for Headway Ireland to maintain all personal data concerning my medical, educational and occupational history relevant to providing me with rehabilitative services
3.  I give consent for Headway Ireland to release reports and information on my rehabilitation and progress to my G.P or other professionals involved in my care
4.  I have read and understood the limits of confidentiality explained above
Applicant’s Signature: / Date:

Please return this completed form to:

Referrals Co-Ordinator, Headway, Unit B3 Link Road Business Park, Ballincollig, Co. Cork

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HFM-089-01 Headway Referral Form