Raleigh House Day Service Referral Form

Waiting List Application

Please use a separate sheet if more space is needed to provide relevant information

Referrer Details
Referral date: / Referred by and position/role: / Organisation:
Phone: / Email:
Client Details
Family Name: / Title: / Gender:
M / F
Forenames: / Date of Birth: / Age:
Address: / Postcode: / Marital status:
Phone: / GP name practice:
Emergency contact details (name, address, telephone number, email, relationship.
NHS NUMBER:
(Please include) / Health System
Number/ID:
Ethnicity:
Religion: / Preferred language:
Spoken: Reading:
Interpreter needed: Yes / No
Problems with hearing: / Problems with
vision: / Any identified barriers to receiving services:
Any potential risks to service staff? (Please provide copy of risk assessment.)
Client written consent given. For information to be shared in confidence with other professional agencies.
Client signature: / Date / Written / Verbal
Reasons for Referral
Description of home situation (e.g. lives alone, is a carer etc); any support client currently receives at home and any other services involved
Raleigh House currently has a waiting list – if the client is not offered a place at Raleigh House what would this mean to them?
Key medical problems, conditions and/or disabilities, falls history: (Tick as applicable)
Mental Health issue (anxiety, depression) / Kidney disease / Discharge from hospital date if applicable
Hypertension / Cancer
Diabetes / Stroke
Dementia / COPD
Heart disease / Asthma
Arthritis / Other
Mobility / Good/fair/poor
[delete as appropriate] / List any aids used
Memory / Good/fair/poor
[delete as appropriate] / Please specify diagnosis if one has been given
Is transport required? Y/N
Is client a member of Dial-a-Ride? / Y/N / If no, do they qualify? / Give details of any parking or access restrictions where client lives.
Does client have a Taxi-card? / Y/N / If no, do they qualify?
Other information
Has the client had a Care Needs Assessment from RBK (Kingston Council)? Y/N. If YES please provide a copy. If NO will they receive an assessment and when?
Is client attending a day service at present? Y / N
If yes, how often (please circle): M / T / W / TH / F Name of service:

Please return completed form to Cathy Weight, Centre Manager, Raleigh House, Staywell,

14 Nelson Road, New Malden, KT3 5EA or by email or fax to 020 8336 0322. For telephone queries call 020 8949 4244.

Staywell is a registered charity number 299988