Care Management/Short-Term Support Service Referral Form

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Care Management/Short-Term Support Service Referral Form

Part 1 – Must Be Completed In All Cases

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Name / Date of Birth
Formal Name (if different to above)
Address
Telephone Numbers
Email Address
Gender / Household Status
Swift ID / NHS Number

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Equality and Diversity (only complete if verified with the person & checked against a code list)

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Ethnicity / Religion / Language
Contact/Relative/Carer Information
Name / Telephone Number
Address / Additional Contact Details
Relationship to you
Carer / Emergency Contact / Next of Kin / Key Holder
Name / Telephone Number
Address / Additional Contact Details
Relationship to you
Carer / Emergency Contact / Next of Kin / Key Holder
Name / Telephone Number
Address / AdditionalContact Details
Relationship to you
Carer / Emergency Contact / Next of Kin / Key Holder

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Hospital Discharge Information

Hospital Discharge? / Select AnswerNoYes
Hospital / Ward / Planned discharge Date
Consultant
GP Practice / GP Name
Other services/named professionals involved (e.g. health and social care):
Reason for referral:
Requested intervention:
Health and social care history and risks:
Environmental risks/Potential hazards: (i.e. dogs, smoker, history of violence)
Entrance to property: (i.e. key safe)
Referrer's Name / Referrer's Role
Base/Dept (if applicable) / Telephone Contact
Address
Consent obtained for referral? / Select AnswerNoYes
If No please provide details
Signature / Date

PART 2 (complete relevant sections if you feel additional detail would be helpful to inform decisions around allocation)

Please give details of problems that require consideration:
1. Accommodation
2. Finance (e.g. managing money, benefits)
3. Self Care and Home Care (e.g. bathing/dressing)
4. Health (e.g. Meds/mental/physical health)
5. Mobility
6. Personal relationships (e.g. family/friends, social contacts)
7. Communication (e.g. sight/hearing, speech)
8. Problems that Carers have (e.g. never get out)
Add below any further referral information not included above

PART 3 FOR OFFICE USE ONLY

Enquiry and referral co-ordinator record
ERC Name
Date and time of initial contact
Date and time form completed (if different)
Referral Information
Referral Source Type
Referral Source Organisation
Outcome (use Swift contact note to document reasons)
Passed to CAT/intake team manager / Closed – inappropriate referral
Signposted to other services (follow signpost procedure) / Person agrees to signpost follow up
Signposted to Support Planners SCHIPs
Admin entry
Swift input by / Date
Community allocation team (CAT) / intake team manager decisions
Allocate to STSS
Allocate care manager
Allocate to Support Planner
Allocated to
Involvement terminated - reason
Signposted to other services (follow signpost procedure) / Person agrees to signpost follow up
Inappropriate referral / Person withdrew
Problem resolved / Other reason (explain below)
Explanation of CAT / intake team manager decision [complete in all cases]
Signature of CAT chair / intake team manager
Name and role
CAT / TM decisions entered on Swift by / Date

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