Touchpoint - Inclusion Barnet | We Believe in the Power of ...



Self Referral FormSection 1: Who is Completing this Form? Please tick the answer which best describes your role: ? I am referring myself to Touchpoint ? I am supporting a friend/relative by completing this referral for themIf you ticked box 1, please skip this section and go to section 2. If you ticked box 2, please complete section 1 before moving on to the other sections. Your first name: Your surname: Name of the organisation you work for (if relevant): Your telephone no: Your email address: Your relationship with the individual who is being referred:From this point, please fill this form out with the details of the person who would like to access this service. Please note we can only accept this referral with the consent of the person who is being referred. Section 2: About YouFirst name: Surname: Like to be referred to as:Date of birth:Gender: Male ? Female ? Non-binary ? Agender ? Genderfluid ? Intersex ? Trans Male ? Trans Female ? Other ? Prefer not to say ? Mobile phone:Landline:Email address:Address:Postcode:GP name:GP surgery name:What is the best way to contact you?? Email ? Landline ? Mobile ? Text Message ? WhatsApp ? Post ? Other (please specify) ________What are the best days/times to contact you?? Anytime Monday to Friday 9am to 5pm ? Mornings only? Afternoons only? Other (please specify) _______Please let us know details of any communication or accessibility needs we need to be aware of:Section 3: Your Current SituationPlease answer the following questions which will help us understand whether Touchpoint will be a helpful service for you: Are you living with any of the conditions listed below?? Yes (please tick all that apply): ? Mental health issues (such as bipolar, schizophrenia, depression, anxiety etc.)? Physical impairment (such as cerebral palsy, multiple sclerosis etc.)? D/deaf or hard of hearing (including tinnitus)? Visual impairment (such as blind or partially sighted)? Neurodiversity (such as autistic spectrum disorder, dyslexia, dyspraxia, ADHD etc.)? Learning disability (such as mild learning difficulty, Down’s syndrome etc.)? Speech impairments (such as stammering, apraxia, dysarthria etc.)? Long-term health condition (such as diabetes, COPD, chronic fatigue etc.)? Other form of disability (please specify) ______? No, I am not living with any of the conditions listed here. Do you live and/or work in the Borough of Barnet? Yes ? No ?Are you finding it difficult to access local services and/or activities that would be helpful to you? Yes ? No ? Please tell us about any other professionals or services you are currently working with (e.g. Social Care/Social Worker, Mental Health Services/Care Coordinator, Support Worker/Care Agency, Local Charity etc.):Service name (if known): Name of the main person you work with (if known):What support do they currently provide to you? Service name (if known): Name of the main person you work with (if known):What support do they currently provide to you? Service name (if known): Name of the main person you work with (if known):What support do they currently provide to you?Service name (if known): Name of the main person you work with (if known):What support do they currently provide to you?Section 4: Reason for Referral Please describe what are the key things you would like to change in your life as a result of working with Touchpoint? (e.g. accessing appropriate housing, reducing isolation, improving physical wellbeing, tackling financial issues, improving mental health, finding employment etc.) Please describe what has so far stopped you from accessing the services or resources that could help you to make these changes? (e.g. difficulty leaving the home, physical access needs, challenges with communication, anxiety about working with organisations, difficulties navigating local services etc.) Section 5: Additional InformationYour safety and the safety of others is very important to us. As such, it would really help us if you could answer as many of the following questions as you feel comfortable to.Over the past year, have you: Been physically violent to others: Yes ? No ? Threatened or intimidated others: Yes ? No ?Hurt yourself physically or taken any dangerous risks with your physical safety: Yes ? No ?Had thoughts about hurting yourself: Yes ? No ?Attempted to take your own life: Yes ? No ?Made plans to end your own life: Yes ? No ?If you answered yes to any of the above, please provide any further details that it might be helpful for us to be aware of: Please provide details of any medical conditions that may need urgent action from someone you are with (e.g. diabetes, epilepsy, severe allergy etc.)Please let us know if there is anything we can do that would help us to keep you and others safeEmergency contact name:What relationship does the emergency contact have with you?:Emergency contact phone no:Emergency contact email address:How did you hear about the Touchpoint service? Google/online search ? A family member or friend ? Another organisation ? Please specify which organisation: _____Touchpoint leaflet ? Please specify from where ____Other ? Please specify _____ Section 6: Privacy Information and Consent FormBy signing below, I confirm that I understand and consent to the following: that as part of their responsibilities in relation to Data Protection and Confidentiality, Inclusion Barnet will:Only keep information for purposes related to my support or care.Make sure that my records are accurate and up-to-date.Make sure that my records are kept no longer than necessary.Make sure that my records and personal information are secure at all times.Make sure that they do not share my data with any other people without my express permission or unless they are legally obligated to. The only exception to this will be where Inclusion Barnet has serious concerns about personal safety or are legally required to. Examples of this include:If there is an immediate risk to your own or someone else’s life or personal safety.If a serious crime has been committed.Please complete either section A or B below (not both). A: If you are completing this form yourself: Do you understand and consent to the above statement on data protection and confidentiality? Yes ? No ?Date referral completed:Your signature: B: If you are completing this form for someone else: Has the individual being referred to Touchpoint a) consented for you to provide the information contained in this form and b) do they understand and consent to the above statement on data protection and confidentiality? Yes ? No ?Do you understand and consent to the above statement on data protection and confidentiality?Yes ? No ?Date referral completed:Your signature: Please return this form:Via email to: touchpoint@.uk Via post to: Touchpoint, Inclusion Barnet, Independent Living Centre c/o Barnet & Southgate College, 7 Bristol Avenue, London, NW9 4BRWhat will happen next? Thank you for taking the time to complete this form. We aim to contact you within 5 working days of receiving a referral. ................
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