1. Details of person being referred:
Name of Person being Referred:
Date of Birth:
Address:
Contact No:
Contact Email:
Mental Health Diagnosis:
2. Who is Making the Referral?
Name and Job Title:
Agency:
Contact Details:
Email address:
Mobile phone number:
If you are unavailable is there someone we can contact in your absence?
Name:
Contact Details:
Email address:
Mobile phone number:
3. Please give the Reasons for Making this Referral
(Please indicate current accommodation and support needs)
4. Is the Referral for a Specific Service? (please refer to brochure of services available)
(If yes please specify below)
5. If the Referral isn’t for a Specific Service What Type of Service are you Making a Referral to?
(Consider for example: staffing levels to meet the individual’s needs, gender specific, culturally specific, geographical location etc.)
6. How Urgent is the Referral?
Level 1 (Urgent) – for example the person is at risk in their current accommodation, homeless; the person is a delayed discharge from hospital etc.
Level 2 (Standard) – for example the person is ready for move on from their current accommodation, their needs have changed but they are not at risk in their current accommodation, they wish to move nearer their family/social network etc.
Please state which level and why this is the case:
What happens next:
  • Referral Enquiry Form received and acknowledged within 1 working day.
  • Contact telephone call from a senior member of Creative Support team to discuss where the referral is most appropriate for within2 working days from receipt of referral.
  • Referral assessments dates will be confirmed within5working daysfrom receipt of referral. If there is an urgent need wewill attemptto fast trackLevel 1 referrals andconfirm a referral assessment date within3 working days from receipt of referral.
  • Senior member of Creative Support team will discuss possible appropriate placements and IB level required. If in agreement to proceed the referrer will book in to panelwith the figure given for cost of placement.
  • Level 2 referral assessments will be conducted within 10 working days of receipt of referral. Level 1 referrals will be assessed within 7 working days of receipt of referral
  • Allocation panel will be held within 2 working days from completion of the assessment for Level 1 referrals and 5 working days for Level 2 referrals.
  • For complex clients we will require third party information and this must be provided in a timely manner and prior to any decision regarding a placement being confirmed.
  • Scheme manager to communicate decision by telephone on the same working day as decision is made to be followed up with an email.
What we need from you:
  • Return this completed form to the email address below.
  • Include the completed Consent to Disclosure Form
  • Attach a copy of anup to date MANCAS. If this is not available the last MANCAS with an up to date Support Plan and current Risk Assessment / Management Plans will be acceptable.
Please note we will be unable to start the referral process if the above information is not attached
PLEASE RETURN THIS FORM BY EMAIL TO