Hampshire SAILSUPPORT REFERRAL FORM
NOTE: Please ensure form is completed in full, with as much information as possible by the referrer.
If you live in Winchester, Basingstoke and Deane, or Hart and Rushmoor, please return to: PO BOX 1783, Southampton, SO18 9LJ.
If you live in Fareham, Gosport, Havant, East Hampshire, Eastleigh, Totton, New Milton, Ringwood, or Andover areas, please return to: South Wing, Admiral House, 43 High Street, Fareham, Hampshire, PO16 7BQ. 173 Southampton, SO18LJ
APPLICANT DETAILSTitle: / Name:
Gender: / Date of Birth: / Age:
Current Address:
Postcode: / Type of current accommodation
(please specify)
Home tel no: / Mobile tel no:
Nat Ins No: / Applicant Email:
Ethnic Origin(please specify)
Dependent children:
Please give information on the names and ages of any dependent children:
Please state if applicant has support from any of the following:
Learning Disability Team Mental Health Team Drug / Alcohol Housing Probation Older Persons Care Team / Physical Disability Care Team / Sensory Care Team
Please attach any additional information i.e. - CAF Reports, Care Plans, Support Plans, reportsor give more details below.
Are there any communication needs? (If yes, please give more information)
Please tick below the type of support needed:
Telephone advice/support
Drop in
Welfare check
Direct 1 :1
(for direct 1:1 support, most outcomes should be achievable in 12 weeks, max of 26 weeks) - maximum of four hours per week(Mon - Fri between 9am and 5pm)
Is this person in receipt of any other HCC or Local Authority funded service? Yes / No
If Yes, will this service be continuing? Yes / No
If the service will be continuing, please outline the support that will be provided:
Full details of support required from SAIL:
List of specific outcomes expected from this SAIL support:
If this referral is for 1:1 hours:
How many hours per week are required to complete these outcomes (maximum 4 hours per week)?
How many weeks of support do you anticipate it taking to achieve these outcomes?
Referrer's Information
Name of Referrer
Name of Referring Agency
Direct Telephone Number
Mobile Number
Risk Assessment
Criminal Record / Convictions:
Has the applicant ever been responsible for any of the following?
Prompts: / YES / NO
Violence which has led to loss of life or serious wounding
Exploitation of others
Sexual offences/incidents
Offences against the state
Arson
Comments - If yes to any of the above, please give as much detail as possible, list dates, any convictions, nature of events and continue on a separate sheet if necessary.
Criminal Record: Please specify below date(s) of convictions and nature of any sentence, which is not spent under the 1974 Criminal Rehabilitation Act.
Is the applicant at risk from:
Prompts: / YES / NO
Self harm
Exploitation / abuse from others
Social isolation
Self neglect
Alcohol consumption
Substance Misuse
If the answer to any of the previous questions isyes, please give as much detail below as possible.
Worsening behaviour and known triggers: Does the behaviour tend to get worse?
Prompts: / YES / NO
After consumption of alcohol or other drugs
When in close contact with other people
When in close contact with family/friends
When bored
When Alone
Is this person currently taking prescribed medication
If yes, please list below / YES / NO
Revised referral form March 2016