Client Self-Referral Form

Required fields are marked with *

Name Of Referrer*

Position*

Referrer Email*

Organisation Name*

Organisation Address

Organisation Telephone*

Section One: Personal

Name of Client:*

Date of birth:*

Nationality:*

Ethnic origin:*

Religion:*

Present Home Address:*

Telephone:*

Previous location:*

National Insurance Number:*

Benefits received and the amount paid to you:*

(please note: clients should be in receipt of a benefit other than housing benefit to be eligible and must have proof of benefits available.)

Does the client have an assigned Social Worker or Community Psychiatric Nurse?:

If applicable, please give details:

Section Two: Next of Kin contact details

Next Of Kin Name:*

Relationship:*

Address:*

Telephone:*

Mobile:*

Section Three: Medical and Psychiatric detail

Diagnosis:*

Please be as specific as possible

Existing Related Symptoms: *

Please give details

Mental Health Section (if applicable) Has the client been diagnosed with a mental health condition?
Has the client had a mental health assessment, if yes please provide details

Are they at risk of suicide?
Do they have suicidal thoughts?

Medication currently prescribed: Please give full details

Section Four: Drugs/Alcohol Use

Please give full details

Section Five: Behavioural Issue

Please give as much detail as possible

Section Six: Criminal Offences

Please give details:

Offence:	Custodial Sentence:	Where was the Sentence served?	Length of sentence:	Dates:
	Yes No
	Yes No
	Yes No
	Yes No

Section Seven: Support Needs

In the referrer's opinion what care, support or supervision requirements does the client have?

Do they need support with debt management?
Do they have any current debts? Please provide details.

Does the client have social interaction issues?
please give details

Describe any problems encountered by the Client with daily living activities:
E.g. cooking, cleaning, taking medication, going out, using public transport, laundry, shopping, budgeting, personal hygiene.

Section Eight: Risks to be noted

Please give details of any risks that need to be taken into consideration in addition to completing the risk assessment at the end of this form:

Section Nine: Bank details

Bank/Building Society/Post office Name:

Savings Account info: (Which bank account, and how much?)

Risk Assessment Checklist - (tick all relevant columns where a risk is identified, please indicate whether it is HIGH, MEDIUM OR LOW RISK based on knowledge of the Service User)

Risk to Self
Risk Factor	high	medium	low
Self Neglect
Abuse by others/financial abuse
Non-compliance with medication
Drug misuse
Self injury behaviour
Alcohol abuse
Anti-social behaviour
Non-engagement with staff
Suicide
Falling


Risk Factor	high	medium	low
Wandering
Choking
Mobility on stairs
Road sense
Environmental risks
Medical problems
Sensory disabilities
Ingesting substances
Other

Risk to Others
Risk Factor	high	medium	low
Violence to family members
Violence to staff
Violence to other residents
Violence to general public
Violence from a third party


Risk Factor	high	medium	low
Threat to children
Sexual offences
Inappropriate behaviour
Other

Risk on transport
Risk Factor	high	medium	low
Seatbelts
Lift on bus


Risk Factor	high	medium	low
Moving around on bus/train

Risk related to property
Risk Factor	high	medium	low
Arson
Damage to property
Theft


Risk Factor	high	medium	low
Rent Arrears
Abandonment
Interference with electricity/gas

Details of any risks identified as medium or high

Any special precautions

Other Risks (Please Specify)

Referrer: How long have you been working with this client ?