Self-Referral Form(When Referring Yourself)

The ARC

Self-Referral Form(when referring yourself)

Name:
I identify my gender as: (please fill in the blank)
Date of Birth: Age:
Address:
Home telephone number:
Mobile telephone number:
Email Address:

Ethnic Group – Tick the most appropriate box to indicate your cultural background (this helps us monitor who we support):

White British / White and Black Caribbean / Indian
White Irish / White and Black African / Pakistani
Cornish / White and Asian / Bangladeshi
Any other White Background / Any other mixed Background / Chinese
Any other Ethnic Group / Any other Black Background / African
Unknown / Any other Asian Background / Caribbean
Information Declined
Please provide details of your GP (including the address and telephone number):
Who else in involved in your care (e.g. CPN, Probation)?
Do you have any specific requirements (e.g. dietary, mobility, disabilities):

Please indicate which of the following options best describes your current status:

Employed full-time (30 hours a week or more per week)
Employed part-time
Self-employed full-time
Self-employed part-time
Unemployed
Full-time student
Retired
Full-time home-maker
Carer
Sick leave
Other (please detail) / 
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Please use the space below to include any diagnosis, symptoms and/or medication. Please be as detailed as possible. The more information we have, the more we can understand the support that you are looking for.
Please let us know how you think The ARC can help?
Do you have any specific concerns/questions about accessing this service?

Costs to accessThe ARC

The ARC will be accessible from summer 2018; our costs will be confirmed prior to this.

In the meantime, if you have any queries regarding this or any other services we offer please contact our office on 01326 378919 or .

Community Psychiatric Nurse support: People wishing to use our service who currently have support from a Community Psychiatric Nurse (CPN), may be eligible for funding. This should be discussed with the CPN at referral stage.

Other Support Agencies: We ask that people wishing to use our service who have support from other agencies (for example, support with housing, mental health, addiction, single parent), discuss the possibility of funding assistance, from that support agency. This should be discussed this with the agency support staff at referral stage.

Subsidies: If a person has no support from any outside agency, we offer a small number of subsidised placements each year. If we are able to offer such a placement, we ask that the individual also make a contribution to the costs, based on their income/savings. Please be aware that as the numbers of these subsidised placements are limited, there can be a waiting list for such places.

Young Person under 18 years of age:Initially, we would look for a referral agency to finance the tariff; if this were not possible tariffs would fall to the young person’s parent(s) or carer.

Please remember: The ARC is a charity and we always strive to keep our costs to an absolute minimum; we want to help; if you cannot afford to contribute anything towards the cost of the placement, please let us know and we will make every effort to help if we can.

Please sign and date below to confirm that the content of this referral form is accurate and that you have understood Sea Sanctuary operates a strictly no smoking policy whilst on board the Yacht.

Print name:______

Signature:______

Date:______

Please return this form to:

The ARC, Waterside Court, Falmouth Road, Penryn, Cornwall TR10 8AW

Or email to

To be completed by The ARC staff only:
Date referral received:
Date initial contact with client made:
Date entered on database:

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