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Elim Centre Kerrier Camborne, TR14 8FH

Redruth Choice Green Lane Chapel, New Cut, Nettles Hill,TR15 1NX

Riveria house Threemilestone Ind Est.TR4 9LD

Office–01209 714782

Email

Name: Address:

D.OB:

N.I. Number: Contact number:

Name of Organisation/Individual Requesting Referral/Registration
Contact Person:
Address:
Tel No: / Mobile:
Email:
G.P.
------
  • Are you aware of the service user being involved with any other relevant services?
Y - N
  • Are there any health issues that we need to aware of?
Y - N
  • Are there any behavioural issues that we need to be aware of?
Y – N
  • Are there any areas of risk that we need to be aware of? i.e. road safety
Y – N
IF YES, PLEASE PROVIDE FURTHER INFORMATION PRIOR TO TRIAL DAY AT CHOICE.
FAMILY/CARER CONTACT DETAILS IF DIFFERENT FROM ABOVE.
Name:
Relationship
Address
Telephone

Fees to be paid by Cornwall County Council

Individually/personal budget/disability cornwall

NHS/PCT

Number of full sesisons required

Number of Half Sessions required

DAYS REQUIRED PLEASE CIRCLE Monday Tuesday Wednesday Thursday Friday

Saturday Sunday

SESSION TIMES 9.00am –3.30 (There may be times, particularly during the summer months, that we may be late back, we will of course inform you of such occasions.)

  • DAILY COSTS (Choice day provision) £40.45 a day £22.00 half day £14.50 per hour for a 1.1 support worker
  • Evening and Weekend Community LinkingFor Individuals who require extrasupport whilstattending Choice we can provide the staff at£14.50per hour

.

By signing this form you are agreeing to up to two half trialsessions at CHOICE.

If after the trial you wish to attend a Choice centre or engage with the outreach support service you will be asked to sign an agreement that will inform you of our terms and conditions. If after the trial you or we decide that Choice is not an appropriate place for you we will not proceed with the registration and there will be no cost incurred to you.

Signed: ______

Name: ______

Date ------

Please return form to

Mandy CrossThe Manager

CHOICE Elim centre

Kerrier Way

CamborneTR14 8FH

Thank you for completing this form.

Elim Pentecostal Church

CHOICE operates under the registered charity number 251549