Mansfield NASS

Nottinghamshire Adults Support Service

This service is for adults in the boroughs of Ashfield, Bassetlaw, Broxtowe, Gedling,Mansfield, Newark and Rushcliffe who are experiencing difficulties due to a learning disability, an Autistic Spectrum Disorder or acquired brain injury and are not receiving a care package from Adult Social Care.

Please email completed referrals to or call to complete via phone on 01623 6750402.

Referral and initial assessment form

If your referral is urgent please contact the local team directly. Please note we will require an up-to-date risk assessment before we can process the referral.

Details of person being referred:

Name: / Date of birth:
Address: / Gender:
Telephone:
GP: / Mobile:
Surgery: / Email:
Date of referral: / Preferred method of contact:

Details of referring person:

Is this a self-referral?
Name of person making referral: / Telephone:
Role (i.e. carer, social worker etc):
Address: Meadow House

Is the service user receiving support from any other agencies?

If “yes” please provide details below:

Is the service user receiving package from Adult Social Care?

Does the service user experience difficulties due to a learning disability, Autism or Austic Spectrum Disorder or as a result of an acquired brain injury?

Please consider whether the person being referred may need support in any of the following areas:
The more details you are able to provide the more this will help us to deal with your referral.

Support to live more independently

Please provide information on current situation and support needed in the following areas: Reduce or manage debts/ Manage bills and budgeting/ Manage or maintain current tenancy(including dealing with evictions or repossession)/ Move accommodation/ Manage security and safety in your home.

Support with health and wellbeing

Please provide details of the current situation and support needed in the following areas: Take care of themselves and keep themselves safe/ Access specialist health services i.e. mental health services/ Access support from drug or alcohol services/ Engage in a healthier lifestyle.

Support to become an active community member

Please provide information on current situation and support needed in the following areas: Access groups and activities in the local community/ Manage relationships with friends and family/ Access to education, training or volunteering.

Any other area of support you feel is not covered above?

Is there any other information we should be aware of?

e.g Any safeguarding issues, any communication difficulties, best method of contact, need for male/female worker etc.

Are there any pets at the property? Please give details.

Equality and diversity information
Collecting this information helps us make sure we are reaching all groups of people fairly.

How would the person being referred describe themselves in terms of the following:-

Nationality: / Ethnicity:
Language: / Religion or belief:
Sexuality: / Marital Status:
Disability: