Referral Form - Rathbone



Referral Form for Rebuild My Life – Crisis Support

Birmingham Rathbone guarantees confidentiality of information received within legal requirements of the Data Protection Act and GDPR. If you are sending us sensitive information electronically, you may want to consider using password protection or encryption.

|Name | |

|Date of birth | |Age | |

|N.I. No | |

|Present Address | |

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|Home Telephone Number | |

|Mobile Telephone Number | |

|Email | |

|What is the nature of the Learning Disability/Difficulty? | |

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|Please state the nature of the Crisis and any other relevant information to support the referral and the reason why the referral has been made. |

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|Is applicant in Local Authority care or currently receiving a care package? |Yes / No |

|If Yes please provide details | |

|Social Worker’s Name | |

|Social Worker’s Office Address | |

|Telephone Numbers | |

|Email | |

|Does the applicant have a recognised appointee for finances/benefits? | Yes / No |

|If yes, please give details of who appointee is: |

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|Doctor’s Name | |

|Doctor’s Address | |

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|Doctor’s Telephone Number | |

|Medical information and details of any specific health problems |

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|BENEFITS |

|Does the applicant get Disability Living Allowance (DLA)? |Yes / No |

|If yes, please indicate below type and level of DLA |Date awarded | |

|Care |High |Middle |Low |

|Mobility |High |Middle |Low |

|Does the applicant get Personal Independence Payment (PIP)? |Yes / No |

|If yes, please indicate below type and level of PIP |Date awarded | |

|Daily Living |Standard |Enhanced |

|Mobility |Standard |Enhanced |

|Does the applicant get any of the below? (Please ( relevant benefit) |

|Job Seekers Allowance (JSA) | |

|Employment Support Allowance (ESA) | |

|WRAG Group | |

|Support Group | |

|Income Support | |

|Working Tax Credits | |

|Child Tax Credits | |

|Universal Credit | |

|State Pension | |

|Private Pension | |

|Learner Discretionary Fund | |

|Disability Bus Pass | |

|Does the applicant get any of the housing related benefits listed below? (Please ( relevant benefit) |

|Housing Benefit | |

|Council Tax Benefit | |

|Discretionary Housing Benefit | |

|Does the applicant get any other benefits? (please list below) |

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|Does the applicant currently attend any of the following? (Please ( below) |

|Employment – Full or Part time |Voluntary Work |Training |Education |Other |

|Employment/Voluntary Work | |

|Employer Contact Name | |

|Employer’s Address | |

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|Employer’s Telephone Number | |

|Number of Hours Employed per week | |

|Current Salary/Wage | |

|Education/Training Provider | |

|College/Training Provider Contact Name | |

|College/Training Provider Address | |

|College/Training Provider Telephone Number | |

|Number of Hours attending per week | |

|Please state any other relevant information regarding Employment or Training or College |

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|Has the applicant any history of the following?: |

|Mental health treatment |Yes / No |

|Criminal convictions |Yes / No |

|Self Harm |Yes / No |

|Alcohol/Substance misuse |Yes / No |

|We can currently provide support to people with learning disabilities in the below areas. What level of support do you feel you need to meet your current needs|

|to achieve your goals? Please circle/highlight/( the most appropriate: |

|Support in setting up and maintaining a home/tenancy |High |Medium |Low |

|Support in developing domestic and practical skills |High |Medium |Low |

|Support in accessing health and social care services | High | Medium | Low |

|Support in developing social skills/managing behaviour |High |Medium |Low |

|Advice, advocacy and liaison with statutory agencies |High |Medium |Low |

|Support in managing finances and/or dealing with benefit claims |High |Medium |Low |

|Emotional support, counselling and advice |High |Medium |Low |

|Support in gaining access to other services e.g. training |High |Medium |Low |

|Support in establishing social contacts and activities |High |Medium |Low |

|Support with home improvements |High |Medium |Low |

|Support in establishing personal safety and security |High |Medium |Low |

|Support in managing risk in the community | High | Medium | Low |

|Supervision and monitoring of health and well being |High |Medium |Low |

|Peer support and befriending |High |Medium |Low |

|Support finding other accommodation |High |Medium |Low |

|Next of kin/parents |High |Medium |Low |

|Siblings |High |Medium |Low |

|Relationship with peers |High |Medium |Low |

|Relationship with authority |High |Medium |Low |

NB. Birmingham Rathbone’s “Rebuild My Life “ project may at some point access or refer on to other appropriate and/or partner organisations, to provide the best and most appropriate support. This would mean sharing this referral information with them. Please ensure you sign below to give consent.

|Consent |

|I agree that this information may be used by Rebuild My Life (Birmingham Rathbone) in dealing with other relevant organisations to provide me with services and|

|support appropriate to my needs, and to send me information which may be of interest to me. |

|Name: | |

|Signature: | |

|Date: | |

|Submitted by (please print name of person completing | |

|form) | |

|Relationship to applicant and/or Organisation | |

|Address | |

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|Work/Home Telephone Number | |

|Mobile Telephone Number | |

|Email address | |

|Does the applicant consent and is aware of this referral?|Yes |

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| |No |

|Signature | |

|Date referral submitted | |

Please return your completed referral form, including the accompanying diversity monitoring form, to the following address:

Birmingham Rathbone

Morcom House

Ledsam Street

Ladywood

Birmingham

B16 8DN

Alternatively scan and email the completed referral form including the accompanying diversity monitoring form to rml@rathbone.co.uk

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