referral form

1. Screening / Referral Taken or completed by: / Date:
2. About the person being referred
CRITERIA / YES / NO / COMMENTS
18 or over?
Have a learning disability?
Live in South Birmingham?

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3. Referrer
Name
Address
Postcode
Tel/Mobile
Email
Relationship to
Person referred
How did you hear
about CASBA?
Has the client agreed to this referral ? / Yes /No
Confirmed / Yes/No
Date:
4. Service User
Name
Address
Postcode
Tel/Mobile
Access to internet
Date of Birth
Accommodation
Is there any
Debt? (Details)

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5. Are there any risks we should be aware of / YES / NO / 6. Are there barriers to communication we should be aware of? / YES / NO
Lone working considered unsafe / Speaks English
Challenging or violent Behaviour / Communicates verbally
Self-Harm / Able to read and/or write
Other, please state / Other
If you answered YES to any of these statements please provide complete full risk assessment found on Page 4 of this referral form / Comments:

Please explain the Presenting Issues:

Name of Advocate taking summary of information …………………………………………………………………………….Date………………………….. OR

Please return this form to: CASBA Advocacy, Northfield House, 751 Bristol Road South, Northfield, Birmingham B31 2NG.

Or scan and email to:

CASBA EQUALITY INFORMATION

CASBA has an Equal Opportunities Policy. This means we provide services to everyone who meet our project criteria, regardless of race, sex, religion or belief, marital status or age. To ensure we follow this policy, we would be grateful if you would give us the following details for monitoring purposes only. Any information given will be treated with complete confidentiality. If you would prefer not to answer any question please tick the box ‘Prefer not to say'.

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Ethnic Background / Please tick as appropriate
White
English/Scottish/Welsh/
Northern Irish/UK
Irish
Gypsy or Irish Traveller
Any other white background
Mixed /Multiple ethnic group
Mixed ethnic background
Asian/Asian UK
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Black/African/Caribbean/Black UK
African
Caribbean
Any other Black/African/Caribbean
Other ethnic group
Arab
Any other
Prefer not to say
Gender / Please tick as appropriate
Male
Female
Prefer not to say
Age / Please tick as appropriate
0 – 24 years
25 – 64 years
65+ years
Prefer not to say
Disability
Disabled: Please tick as appropriate
Mental Health
Sensory Impairment
Non verbal
Physical Disability
Other
Not disabled
Prefer not to say
Religion / Please tick as appropriate
No religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other religion
Prefer not to say
Sexual Orientation / Please tick as appropriate
Hetrosexual
Lesbian, gay man or bisexual
Prefer not to say

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CASBA Risk Assessment

Client Name: ______

Completed By: ______Date: ______

Please tick all boxes applicable
Verbal abuse
Aggressive or intimidating behaviour
Problems with working with either female of male staff
Non-Cooperation with staff
Issues around mental illness
Issues around drug or alcohol use
Issues around criminal or anti-social behaviour
Financial abuse
History of rape or sexual assault
Accidental fire setting /Arson
Lone working considered unsafe
Problems with working in a group (own vulnerability or risk to others in group)
Detail of risk (Include details of last known incident & frequency)

Type of risk (Tick as many as apply)

Who is at risk? (Tick as many as apply and provide details where appropriate in the space provided)

Self
Staff
Family and friends
Specific individual(s) (specify)

Assessment of risk

High – To be reviewed at least monthly.
Medium – To be reviewed at least every two months
Low – To be reviewed at least every six months
No known risk

Risk Assessment Action Plan

Triggers / behaviour to be aware of:
What to do to manage risk / What to do if major risk to self or others (e.g. who to contact)

Is the person aware of this assessment? Yes / No

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