Referral for Residential Care Accommodation

NAME

DATE OF BIRTH

CURRENT ADDRESS

/ Length of Time at Current Address:

NEXT OF KIN

/ Name:
Address:
Contact Telephone Number:
CONSENT TO SHARE / A consent to share information with The Society is attached Yes/No
(This form is required for The Society to accept this referral)
N.I. NUMBER (if known):

GP

/ Name:
Address:
Contact Telephone Number:
NHS NUMBER (if known):
MEDICAL HISTORY
(Please use additional sheets if required) / Please give details of medical history, including any long-term illness/condition and current treatment, mental health conditions, alcohol/substance dependency and any other conditions E.g. Asthma, Bronchitis, Migraines:
CARE NEEDS – Please answer the following sections with as much detail as possible, selecting the level that you believe to be most appropriate for the client. The Registered Manager will assess the client following receipt of the referral and make the final decision about the level of need. Failure to provide accurate information may lead to a delay in progressing the referral or withdrawal of the placement.
Level 1: Able to carry out all elements in this area with minimal assistance
(E.g. needs help to get in the bath or shower but is able to wash themselves)
Level 2: Requires hands on assistance in this particular area
(E.g. needs help to get in and out of the bath/shower, help with washing, drying and dressing)
Level 3: Requires hands on assistance in this particular area and presents some challenging/difficult behaviour
(E.g. needs help to get in and out of the bath/shower, help with washing, drying and dressing; has a mental health diagnosis, Dementia or challenging behaviour linked to alcohol dependency)
Level 4: Requires one to one support assistance at all times in this particular area and presents severely challenging behaviour related to mental health problems, Dementia or severe alcohol dependency.
CARE NEED / Level 1 / Level 2 / Level 3 / Level 4
Bathing and washing
Dressing and
undressing
Other personal care
(Hair care, shaving, teeth)

Eating & drinking

(able to feed self and drink unaided or needs assistance)

Mobility

(Please provide details of any walking aids used, stairs are manageable,
how far individual is able to walk)

Communication

(Please give details of any sight, speech or hearing difficulties, including any aids used)

Please provide accurate and full details where relevant in the following section; risk assessments for each area will be completed on admission:

Behaviour Issues / Learning Difficulties
Current Alcohol Consumption Level
Current / Other Substance Use
Depression/Anxiety/
Panic Attacks
(Please give details if relevant)
Allergies
(Please provide details of any allergies E.g. food allergies, penicillan, soaps etc.)
Hobbies/Interests

Social Network

(Please provide information about clubs, day centres, support groups attended, friend circle, family support)

Likes/Dislikes

(Please give details of any specific likes/dislikes including food, drinks, TV programmes, travelling etc.)

Daily Tasks

(Please give details of ability to prepare drinks, sandwiches, toast, breakfast cereal etc.)
Criminal Record
(Please provide details of any criminal convictions or pending criminal convictions, including court orders, possession orders, drug treatment orders and community service orders)

If the individual has lived in supported housing previously, has he/she ever been issued with any warnings or been evicted as a result of violence or intimidation of staff or other residents.

Most Recent Mental Health Assessment Attached

/ Yes/No

Most Recent Risk Assessment Attached

/ Yes/No

MEDICATION

Self Medicating YES NO
TYPE / Strength (Mg) / Frequency
Smoker / Non-smoker / IF YES, HOW MANY DAILY?
Is there a named Social
Worker? YES / NO / If YES, please give details:
NAME:
TELEPHONE:
EMAIL:
TEAM/DEPARTMENT:
Is there a Named Care Manager?
YES / NO / If YES, please give details:
NAME:
TELEPHONE:
EMAIL:
OFFICE ADDRESS:
Is the client self-funding?
YES / NO / If YES, please tick preferred method of payment:
Weekly by Standing Order £
Weekly by cheque £
Monthly by Standing Order £
Monthly by cheque £
Is the client funded by the local authority?
YES / NO / If YES, has the funding for the care placement been agreed? YES / NO
If NO, please provide the date of the next funding application meeting:
NAME OF PERSON MAKING REFERRAL

ORGANISATION

/ Name:
Address:
POSITION IN ORGANISATION
CONTACT TELEPHONE NUMBER
DATE OF REFERRAL
SIGNATURE / I confirm that I have provided as much information as possible and that I am authorised by my organisation to make this referral.
Signed: ______
Date: ______

Please return the completed form to:

The Manager

St James Care

106-108 Radstock Road

Woolston

SOUTHAMPTON

SO19 2HR

Email: or

Fax: 023 8033 9026

Head Office Address:

The Society of St James, 125 Albert Road South, Southampton, SO14 3FR

Telephone: 023 8063 4596 Fax: 023 8033 9026

Registered Charity No: 1043664 Website: www.ssj.org.uk

St James Care – Referral for Admission

Reviewed November 2013 Next Review due November 2015 Nicola Butler Page 2 of 2