Referral – Detailed Form Please enable JavaScript in your browser to complete this form.If you need any advice or have a general question please use the contact us webpage. If you prefer to speak to someone please call the office on 01784 245 817About YouFirst NameSurnameDOBAge nowGenderCurrent AddressContact NumberNext of KinFirst NameSurnameRelationshipCurrent AddressContact NumberCurrent GPFirst NameSurnameCurrent AddressContact NumberDiagnosesYour Current PlacementCurrent AddressContact NumberDo you share or live aloneAre there any problems with where you currently live?How you communicateWhat is your first language?Do you speak any other languages?Do you communicate verbally or non verbally?Do you use Makaton or sign language?Do you have speech therapy sessions?Any other comments?Personal LifeDo you have a religion?Describe your abilities/attitudes and lifestyle:Describe your personal history (eg family dynamics)Describe your social network:Key people in your lifeNameRelationshipHow often do you see them?NameRelationshipHow often do you see them?NameRelationshipHow often do you see them?Personal Care / Dressing Comment on the support needed around a you accessing the toilet.Comment on your personal hygiene and the support you require; (bathing, washing, hair, teeth, shaving, ears, nails, menses)Comment on the support needed around your dressing yourself (including choice of daily attire, underwear, shoes etc)Have you had a capacity test and best interest meeting about your capacity to consent to personal careEating and DrinkingWhat foods do you mainly eat?What foods do you eat?Are you allergic or intolerant to any foodsDo you have any specific dietry needs?What do you mainly drink ?What drinks do you not drink?Domestic SkillsAre you able to do washing and ironing? Do you require support with this?Are you able to clean and maintain a good standard of cleanliness within your home? Do you require support with this?Money ManagementAre you able to manage your own money? Do you require support with this?Are you in reciept of any benefits, if so what?Do you have capacity to manage or instruct others to manage your money?Have you had a capacity meeting around your money?Have you had a best interest meeting around your finances?Have you got an appointee or guardian to support you to manage your money?OrientationDo you access your local area?Are you able to travel further a field unsupported?Are you aware of dangers? E.G strangers, crossing roads, getting lost.Social SkillsDo you have any hobbies?Do you have a job or do you attend college or a day centre?How do you feel about meeting new people?What activities do you like doing?General HealthDiagnosis of any health problems:Any Illnesses?Any allergies?Comment on your respiration:Comment on your fluid intake:Comment on your nutritional intake:How is your mobility? Do you need any support with this?Comment on your sleep pattern: Do you need support in night?Comment on your vision:Comment on your hearing:What is your height?How much do you weigh?Do you visit your GP regularly e.g for check ups?Do you have a physiotherapist?Do you visit occupational therapy?Do you visit Art Therapy/ Music TherapyDo you visit a dietician or nutritionalist?Do you visit a speech therapist?Do you visit a chiropodist?Do you have a dentist? When did you last visit the dentist?When did you last visit the optician?Do you have any sexual health or contraception needs ?Do you smoke?Do you take any kind of drugs?Do you take medication? If yes what medication?Do you have capacity to administer your own medication?Do you have capacity to instruct others to administer your medication?Have you had a mental capacity assessment ?Have you had a best interest meeting around capacity to consent to medication?Behaviour of ConcernDo you ever display behaviour of concern?If Yes, what trigger’s this behaviour?What do you do during this time? E.g are you physically or verbally abusive?What helps you to calm down when you get anxious?How long does it take you to return to your normal baseline behaviour?Where does this behaviour normally occur?Are there any triggers for your behaviour that you are aware of?Have you ever self harmed?Any other comments around behaviour?Your Goals and AspirationsWhat are your likes ?What are your dislikes ?What are your dreams and aspirations for the future?Describe what your perfect day would be.Any mental capacity assessments and outcomes : SubjectAny mental capacity assessments and outcomes: ConclusionAny best interest meetings under Mental Capacity Act 2005: SubjectAny best interest meetings under Mental Capacity Act 2005: ConclusionAny LSP (Liberty Safeguarding Protections) in place or applied for : SubjectAny LSP (Liberty Safeguarding Protections) in place or applied for: ConclusionMain Care Needs:Possible Risks:Any adaptions/alterations required? (e.g hand rails, special bath/shower, wheelchair ramps etc)Any further comments from present Care Givers - regarding care needs/risks.Any further comments from Care Manager - regarding care needs/risks.Any further comments - regarding care needs/risks.Date of Assessment:Name of Person Completing Assessment:Position: Sign:Submit
