Service User Information

Referral Form

Application for (if known, please put a cross in the appropriate box )
Appointee / LPA / Deputyship
Referrer Name:
Referral Date: / Contact Number:
Email Address:
Occupation:

Service User Information

Title: / First Name: / Middle Name: / Surname:
Date of Birth: / NI Number: / Status: (delete as appropriate)
Single/Cohabiting/Married/Divorced/Widowed/Other

If married or cohabiting, please provide their partners details below.

Partner Name: / Date of Birth: / NI Number:

Accommodation Details

Full Address:
Number of adults living
at this address:
(Please provide names/DOB)
Number of children living at this address:
(Please provide names/DOB)
Contact Name/Number:
Previous Address
(if applicable)
Housing Category:
(mark box with a X) / Housing Association
Private Landlord
Residential Care
Supported Living
Accommodation / Nursing Home
Own Home
Hospital
Rehabilitation Unit
How is their accommodation funded?
(mark box with a X) / Self
Local Authority - Does the client pay a contribution/top-up?
NHS - Continuing health care
NHS - Funded Nursing Costs
S117
Deferred Payment
Housing Benefit - please state the Local Authority that administers this

If in residential or nursing home, is this an interim or long term placement?

If the accommodation is rented please provide the Landlord’s details below. Pleaseprovide a copy of the tenancy agreement.

Housing Association /
Landlords Name :
Address:
Contact details:
Property Type: / House (Semi-detached)
House (Detached)
House (Terraced)
Flat / Apartment
Bungalow
Maisonette
Heating Type: / Gas / Electric / Oil
Number of rooms:
Approx age of property:

Welfare Benefit & Income Types

Amount / Payment Frequency
(Weekly/Fortnightly/monthly)
Housing Benefit
Council Tax Support
State Pension(SP)
Pension Credit (PC)
Private or
Occupational Pension
Disability Living Allowance (DLA)Care
Disability Living Allowance(DLA) Mobility
Personal Independence Payment (PIP)
Attendance Allowance (AA)
War Widow's Pension (WWP)
Income Support (IS)
Job Seekers Allowance (JSA)
Incapacity Benefit (IB)
Employment & Support Allowance (ESA)
Severe Disablement Allowance(SDA)
Industrial Injury Disablement Benefit (IIDB)
Widow's Pension (WP)
Working tax credit
Child Tax Credits
Carers Allowance
forsomeone they arecaring for
Is someone receiving carers allowance for the client? / Yes / No

Debts/Outgoings

Please identify any known debts that the client has (such as unpaid bills, any longer term debts that may have triggered the involvement of debt agencies)
Does the client have home contents/buildings insurance? If so please provide details
Yes/No
Does the client have a funeral plan in place? If so please provide details
Yes/No
Client’s current beliefs or religions:

Care Provision

Who is currently providing the care for this client? / Family
External agency - in own home - Please provide details in box below
Nursing or Residential Home Staff
District or community nurses - Please provide details in box below
Other
please state
Care Agency Name:
Address:
Contact Name(s):
Contact Number:
Contact Email:
How is care funded? / Self
Local Authority Funding - is client required to make a contribution?
NHS - Funded Nursing Care
NHS - Continuing Healthcare Care
Other - please state
Has the client ever received NHS funded care? / Yes / No
Have the client's care needs been assessed by the NHS? / Yes / No
Has the client ever had to pay towards the cost of their care (since April 2012)? / Yes / No
Is a care plan in place? If yes, please provide a copy, if no is one due to be undertaken? / Yes / No
Personal budget details (including amount of hours for care/support worker and any hours/money for other support such as attending day centre)
Is there a direct payment in place (if so how much is it for per week/month)
Who manages the direct payment: Client, family/friend, managed payroll organisation (please give details)
Has a Financial Assessment been completed by the Local Authority(please give approximate date and provide a copy of the latest one.)
Date of last care bill:
GP Surgery:
GP Address:
GP Contact Number:

Assets and Capital

Please provide a copy of the latest statements for all bank/building society and post office accounts. Please supply where possible details of other capital and investments.

Account details/reference numbers / Approximate balance/value
Bank Account:
Post Office Account:
Stocks or shares:
Investments:
Properties including their
own home and investment rental properties: – please state
Inheritance: /
Compensation:
Other:

We can also open a new bank account for the client with our partner bank, Advance Payment Solutions if they do not have a current bank account or do not have access to the money in their current bank account.

We also have a carer’s card that can be issued if you would like a designated person to have access to limited funds for shopping etc? This would be a card in that person’s name.

Please circle which option is best for you or your client:

Use current bank account / use The Money Carer Foundation banking services / apply for a carers card

If you would like to apply for a carer’s card please state the full name and title and address of the person who will be named on the card.

Please note there are additional costs for setting up a new bank account or having a carer’s card. Please ask for further details.

Overview of Service Users Circumstances
d

Has a Capacity Assessment or best interest meeting taken place?
If, yes what was the outcome? Please provide a copy.
Yes/No
Has the Client made a will?If yes, please provide the details of who holds the will? If no, has a full search been undertaken to ensure that a will is not place?
Yes/No
Is there a current Appointee, Lasting Power of Attorney or Deputy in place?
If yes, please state who and have they agreed to relinquish?
Yes/No
Has any legal order been made from the Mental Health Act or the Mental Capacity Act including Deprivation of Liberty (DoL)? Please provide details
Yes/No
Is the client part of a current safeguarding process as a result of concerns?
Yes/No
Has the client experienced fraud or financial scamming?
Yes/No

Vulnerability/Disability Diagnosis

Please provide as much detail as possible in this section to help us assess if the client is accessing all the benefits and allowances that they are entitled to.

Family / Friends Contact Details

Has the referral been discussed with the client and their family or friends if applicable? Please provide contact details of family and friends

Other Information:

Please use this page to provide any additional information that may assist us with supporting this service user.

Please also refer to the accompanying Procedures and Policies Document as this will provide helpful information about our standard operating processes. Completed referral forms will be accepted as acknowledgement that this document has been read and understood.

Please email the completed form or fax to 01928 551921.

Alternatively post this form to us as follows:

The Money Carer Foundation,
The Heath Business & Technical Park,
Runcorn, Cheshire,
WA7 4QX.

Checklist

Please indicate if you have attached the following documents as requested in the referral form.

Name of Document / Included / To follow / Not applicable
Tenancy Agreement
Recent bills
Care plan
Financial Assessment
Bank Statements
Post Office Statements
Private Pension Provider
Capacity Assessment