To be completed by Care Coordinator and client / All personal information is held under the data protection act and is strictly confidential. PLEASE PRINT CLEARLY AND COMPLETE ALL FIELDS AND RETURN TO: or by post to: RAW SOUNDS, RAW MATERIAL, 2 ROBSART STREET, LONDON SW9 0DJ
First Name: / Last Name: / Date today:
Date of Birth: / Age: / Gender:
Address: ______
Post Code: ______Borough: ______
Phone: ______Mobile: ______Email Address: ______
Are you currently using mental health services? Yes [ ] No [ ]
If yes, please state borough______Name of Trust______
Mental health service(s) you are currently using e.g. In-Patient, Forensic, Early Intervention, CMHT etc)
______
Do you have a care coordinator or Key Worker? Yes [ ] No [ ]
If yes, please provide name: ______Job Title ______
Contact Number______Email______
What is the service name, department, ward, etc the coordinator works for?
Do you have a CPA? Yes [ ] No [ ]
Do you have: Personal Budget? Yes [ ] No [ ] AND/OR Direct Payments Yes [ ] No [ ]
If No, do you expect to be assessed for self directed support within the next 12 months? Yes [ ] No [ ]
If No, have you ever applied for self directed support and been unsuccessful? Yes [ ] No [ ]
Emergency Contact Name: / Relationship: / Contact Number
We want to ensure our programme/ facilities are equally accessible for everyone, please provide any additional details/requirements that could help us achieve this (e.g. physical assistance, materials in different format).
How would you best describe your cultural background? / White British / White & Black African / Pakistani/British Pakistani / Black African
White Irish / White & Asian / Bangladeshi/British Bangladeshi / Black Other
Not Stated / White Other / Mixed Other / Asian Other / Chinese
White & Black Caribbean / Indian/British Indian / Black Caribbean / Other
Are you in further education? / Full time / Part-time / Are you working? / Full time / Part time
Registered Unemployed? / Are you receiving benefits? / If yes please specify
Have you enrolled in any Raw Sounds projects in the past?
Yes [ ] Give details No [ ] / Do you have any experience of playing, performing or producing music or media?
Yes [ ] Give details No [ ]
Which of our activities are you interested in?
Songwriting, live music and performance skills [ ]
Music Technology [ ] Studio Recording [ ]
DJ’ing [ ] / Why would you like to come to Raw Sounds?
Places on our courses are limited and subject to availability. If you are offered a place you will be asked to sign an agreement to attend sessions regularly and on time for the term or reminder of the term, on which a place is offered.
Will you be willing and able to commit to this? Yes[ ] No [ ]
Your Signature / Date
Raw Sounds Risk Assessment
Raw Sounds is committed to providing a safe environment for aspiring musicians and filmmakers.
This document is to assess the risk of the client attending Raw Sounds. Information provided is confidential and will not be shared with third parties.
Does the client have a history of violence and aggression?Y / N
Has the client made specific threats to harm others?Y / N
Does the client misuse drugs/ alcohol?Y / N
Has the client recently been discharged from hospital (within the last 6 months)Y / N
Does the client have a history of non-compliance/ disengaging with aftercare?Y / N
Has the client recently disengaged with care/ stopped medication?Y / N
Does the client present a risk of inappropriate sexual behaviour?Y / N
Is there a risk of exploitation from others? (financial/ sexual/ physical/ emotional)?Y / N
Does the client feel comfortable in a group setting?Y / N
Summary of Risk:
Relapse indicators (please state any known indicators of relapse):
Trigger Factors (please state any known trigger factors (eg substance misuse etc):