Enrych Assist Personal Assistant Support Service

Enrych Assist Personal Assistant Support Service

Referral and Enquiry Form

(Health and Social Care workers)

Confidential

In East Midlands: Please return to : or + Enrych, Marlene Reid Centre, 85 Belvoir Rd, Coalville, LE67 3PH. ( 01530 832 926 for any queries.

In Oxfordshire: Please return to : katie.spyve @enrych.org.uk or + Enrych, E14 Holly Farm Business Park, Honiley, Warks, CV8 1NP ( 07720 089 477 for any queries.

If you fill in this form on a computer, type in the shaded areas. To move to another shaded area, use the ‘Tab’ key or the leftï and right ð arrows on the keyboard. Or you can click/tap to select

Client details

Preferred Title First name(s) Surname
Address :
Post Code: / Date of Birth (dd/mm/yyyy)
Telephone - Home:
Telephone - Mobile:
Email address:
Local Authority ID No:
Client’s preferred contact method: (click on the box to select)
home phone mobile phone email other
Best time of day (eg after 10am, between 9 and 2pm etc)
Days available
Any particular communication requirements?
How did you hear about Enrych?

Contact people in case of emergency

1st contact name: / Relationship to client:
Tel Nos Home Work Mobile
Address:
Post Code:
2nd contact name: / Relationship to client:
Tel Nos Home Work Mobile
Address
Post Code:

Information about the client

Please tell us about the client’s disability. What is the disability and how does it affect the client? (Include any factors which may be relevant to an activity eg epilepsy, agoraphobia, diabetes)
Please tell us about the client’s interests and the things they like doing
Are there other issues, circumstances or conditions that we need to know about? (Eg things that might affect behaviour, social interactions, anything regarding safeguarding issues)
Why is the client coming to Enrych?
What activities/tasks does the client want support to do?
How many hours of PA support will they need each week?
Please list the days and times required:
Does the client have agreed Outcomes in a local authority Support Plan? Yes No
Details of outcomes:
What is the source of finance for PA support?
Personal Budget (direct/cash payment) Personal Budget (LA managed service)
Self-funded Enrych Provider Managed Account service? Yes No
Local authority contribution to non-residential social care services £

Other Agencies involved in care

Name of organisation / Contact person / Phone / Email
Care Manager

Client’s Personal Profile

What’s important to me
Things I want my PA to support me to do / What difference will this make to me?
Information relevant to risk assessment
This role involves Manual Handling Food preparation Use of car
Other...
Tasks required
Shopping Yes No Assist in/out of vehicles Yes No
Cleaning Yes No Assisting in leisure activities e.g. swimming Yes No
Preparing meals Yes No Driving activities e.g. visit friends/hospital Yes No
Any other tasks please specify:

Please tick (click box) tick to confirm your client is aware you are referring them to Enrych, and they are happy for us to contact them

Referrer’s Name

Job Title Organisation

Email Phone

Referrer’s Signature: Date:

Typed names received via email will be acceptable as a signature

Please send this back to us at Enrych. You can email it or post it – address on p1.

For Enrych use

Relevant medical history (physical and mental health):
Triggers and indicators:
Coping strategies and techniques:
Relationships:
Current support in place:
Additional PA training requirements: (eg Epilepsy, Moving and Handing, Food Hygiene)
Date / Details / Enrych worker

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