The Julian House meaningful activities and trainingservice is based at Space2, 55 New King Street, Bath. The service delivers a program of Independent Living, Health & Wellbeing and Employability activities from Monday to Friday. The service works with those in receipt of housing related support, with substance misuse issues, with low level learning difficulties, mental health issues or offending backgrounds. The service offers a range of timetabled activities that are reviewed regularly to meetthe need of service users.
Access to the service is through service user and referral agency completion and return of the referral form below. Service users are offered a brief assessment andinduction upon attendance of first activity session.
Meaningful Activities Referral Form
Referred personsdetails Referral date:
First name: Surname:
Address:
Post code: Date of birth / / M/F
Telephone: Email:
National insurance number:
Current work status; Job seeker employed part time 24hours or less
voluntary work employed full time, more than 24 hours
long term sick not seeking work
retired
Learning support & disability:do you consider the referred person to have;
a disability
a mental health difficulty
a learning disability
low literacy
Nature of disability:……………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………….
Ethnic Origin:
White Asian or Asian British Black or Black British
British/Welsh/ Scottish Bangladeshi African
Irish Indian Caribbean
Traveller Pakistani any other black/African/
any other Chinese Caribbean background
any other Asian background
Mixed / multiple ethnic group other ethnic group
White & Asian Arab
White & Black African any other ethnic group not specified
White & Black Caribbean
any other mixed ethnic group
Does the referred person experience any of the following issues?
Accommodation / Active offending / Offending background Alcohol / Anti-social behavior / Debt or financial
Drugs (incl, prescribed) / Physical Health / Self-harm
Domestic Abuse
Medical History
do you have any health or medical condition ? Y / N if yes please list………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Do you take any medication ? Y / N if yes please list
……………………………………………………………………………………………………………………………………………………………………………………………......
Have you undergone any recent surgery ? Y / N if yes please give details
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...
Do you suffer from any allergies ? Y / N if yes please give details
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
Referral agency details:
Name: Service referred from:
Telephone: email:
Does the referred person receive support from referral service? YES / NO
Detail of support:
Does the referred person have an up to date referral agency risk assessment? Please attach a
copy. If no please contact us to discuss this referral.
What does the referred person wish to gain from being involved in our meaningful activities project?
…………………………………………………………………………………………………………………………………………………………………………………………………………………….
Please tick the activities theywish to participate in(see Space2 timetable of activities).
Football: fix a bike:
Over 50’s: tennis:
Beginner’s IT: IT drop in:
1;1 literacy/ Dyslexia support: advanced cookery (Friday):
Acupuncture & meditation : holistic therapies:
Women’s Bakery; women’s crafts:
Confidence booster *September career booster *September:
Interview success * September * dates to be confirmed for these 3 courses
“Resilience group”(dealing with setbacks, confidence building, leading a fulfilling life):
Signed: Print name:
Please return completed form to address or email below :
Space2
55 New King Street
Bath
BA1 2BN
Tel: 01225 354780
Julian House staff use only
Client on inform;
Timeline completed;
Client contacted ;
Agency Contacted;