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DIAMONDS SHELTERED HOUSING
REFERRAL FORM
SEMINARS AND COACHING
RESOURCES
T:
01213 844484
REFERRAL FORM
Please leave blank:
TYPE OF SERVICE REQUIRED.
Please select one of the following:
Drugs Rehabilitation
Alcohol Rehabilitation
Post Traumatic
Stress Disorder
Rehabilitation
Other Addiction Rehabilitation Supported housing
Floating support
Name of preferred service:
GENERAL INFORMATION
Preferred tittle:
Please select
Miss
Ms
Mr
Mrs
other
Name:
Known as:
Email:
Address:
GP: Dr:
GP Tel No:
Consultant Tel No:
CPN Tel No:
DOB:
Religion:
First Language:
Social Worker:
Nearest of Relative:
Tel No:
Address:
Does applicant have a CPA:
Yes
No
Is there a current risk assessment:
Yes
No
Tel No:
GP Address:
Consulant:
CPN:
Your Age:
Nat Ins No:
Ethnic Orgin:
Speaks/Understands English:
Socal Worker Tel No:
Address:
Statutory Key-worker:
Tel No:
Who has responsibility for funding and benifits:
Detail of significant other involved in support:
SECTION 2
to be completed by the service user.
Briefly describe the sort of life you would like to achieve and the ambitions and goals you have for the future?
What sort of support would you want from Diamonds Sheltered Housing to enable you to work towards this goal?
.How would you describe your life at present under the following headings?
Accomodation:
Yes
No
Are you satisfied with this area? :
Yes
No
What you do during the day:
Friendships:
Yes
No
Finance:
Yes
No
Family:
Yes
No
Support from mental health services:
Yes
No
Please indicate why you are making this application, for example do you see this as a positive move for you personally at this time in your life or is it a suggestion of the statutory worker:
How would you describe your mental health and emotional state at this time in your life?
Please indicate why you are making this application, for example do you see this as a positive move for you personally at this time in your life or is it a suggestion of the statutory worker:
SECTION 3
to be completed by the statutory keyworker or other health care professional with the support of the applicant
Reason for referral. (Please indicate the reasoning for the chosen service):
Significant psychiatric history, (Include details of hospital admissions):
Current physical health issues:
What is your assessment of the persons needs?
Brief history:
Details of current medication:
What is your current involvement in support arrangements?
What will your involvement be in future support arrangements:
Are there any past or present risks that Diamonds Sheltered Housing should be aware of?
Arson:
Yes
No
Self harm:
Yes
No
Suicide:
Yes
No
Aggression and violence:
Yes
No
Exploitation:
Yes
No
Severe self neglect:
Yes
No
Other:
Explain:
Is the person currently subject to a section of the Mental Health Act? :
Yes
No
Will the person be subject to a Section of the Mental Health Act during their placement?
Yes
No
Is the person subject to Section 117:
Yes
No
Are there any warning signs that usually precede risk issues / triggers? :
If yes please indicate which Section:
If yes please indicate which section of the Mental Health Act :
Has funding for the placement been applied for?
Yes
No
Name of budget holder:
If no please specify:
How many hours of support has the individual been assessed as needing? (Residential and floating support only):
Status of funding:
Pending
Approved
Does the person have control of his/her finances:
Yes
No
Will the person be subject to a Section of the Mental Health Act during their placement?
Yes
No
Have the following reports been attached?
Medical report:
Yes
No
Social Workers report:
Yes
No
Current CPA:
Yes
No
These reports are required for all residential related services.
Submit
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